preliminary training for drug evaluation and ... iwai, oregon state police ... developed as part of...

Preliminary Training for Drug Evaluation and Classification

Program

“The Pre-School”

Participant Manual

DRE Pre-School Instructor Guide – Table of Contents

R5/13 Curriculum

Acknowledgements

Preface Page

Administrator’s Guide

Session I: Introduction: Preliminary training for the DEC Program

Glossary of Terms

Session 2: Overview of the DEC Procedures

Session 3: Psychophysical Tests

Session 4: Eye Examinations

Session 5: Alcohol Workshop

Session 6: Examination of Vital Signs

Session 7: Overview of Signs and Symptoms

Session 8: Alcohol as a Drug

Session 9: Preparing for DRE School

Session 10: Conclusion of the Preliminary Training

Acknowledgements The International Association of Chiefs of Police (IACP) and the National Highway Traffic Safety Administration (NHTSA) would like to thank the following individuals for their contributions in updating and revising the 2013 DRE curricula. Jonlee Anderle, Laramie, WY Police Department

Kyle Clark, Institute of Police Technology and Management

Don Decker, Nahant, MA Police Department

Ernie Floegel, International Association of Chiefs of Police

Chuck Hayes, International Association of Chiefs of Police

Mike Iwai, Oregon State Police

Jim Maisano, Norman, OK Police Department

Evan Graham, Royal Canadian Mounted Police

Bill O'Leary, National Highway Traffic Safety Administration

Doug Paquette, New York State Police

Preface

The Drug Recognition Expert course is a series of three training phases that, collectively, prepare police officers and other qualified persons to serve as drug recognition experts (DRE). Throughout this manual, the terms “drug recognition expert” and “DRE” are used to designate an individual who is specially trained and has continued training to conduct examinations of drug-impaired drivers. This training, developed as part of the Drug Evaluation and Classification Program (DECP) under the auspices and direction of the International Association of Chiefs of Police (IACP) and the National Highway Traffic Safety Administration (NHTSA) has experienced remarkable success since its inception in the 1980s.

As in any educational training program, an instruction manual is considered a “living document” that is subject to updates and changes based on advances in technology and science. A thorough review is made of information by the DECP Technical Advisory Panel (TAP) of the Highway Safety Committee of the IACP with contributions from many sources in health care science, toxicology, jurisprudence, and law enforcement. Based on this information, any appropriate revisions and modifications in background theory, facts, examination and decision making methods are made to improve the quality of the instruction as well as the standardization of guidelines for the implementation of the Drug Recognition Expert Training Curriculum. The reorganized manuals are then prepared and disseminated, both domestically and internationally, to the DECP state coordinators.

Changes will take effect 90 days after approval by the TAP, unless otherwise specified or when so designated by a state coordinator.

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Participant Manual DRE Pre School - Session 1 – Introduction: Preliminary Training for Drug Evaluation and Classification Program


Session 1 - Introduction: Preliminary Training for Drug Evaluation and Classification Program

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Session 1

Introduction:Preliminary Training for Drug Evaluation and Classification Program

35 Minutes

Welcoming Remarks Faculty Introductions



Program

Housekeeping

• Paperwork

• Mandatory attendance

• Breaks

• Facility

• Interruptions • All electronic devices off

Administrative Matters

1-2

Paperwork Attendance

Attendance is mandatory at all sessions of this school.

Breaks Facility Interruptions

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Participant Introductions

• Name

• Agency

• Affiliation

• Experience

1-3



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Goal: To prepare the participants to succeed in the 7-Day Drug Recognition Expert School

Introduction

1-4

Preliminary Training Goal

To prepare the participants to succeed in the 7-Day Drug Recognition Expert school.

This two-day Preliminary School won’t make you DRE’s, but it will make it easier for you to pass the 7-Day DRE School and successfully complete your certification training.



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• Define the word “drug” • Name the seven categories of drugs• Identify the twelve components, or

steps, used in the DRE drug influence evaluation

• Administer and interpret the psychophysical (or “divided attention”) tests used by DREs during the drug influence evaluation

Course Learning Objectives

1-5

Learning Objectives of the Preliminary Training

• Define “Drug” and name the seven categories.

• Name the seven categories of drugs.

• Identify the twelve components or steps in the DRE drug influence examination.

• Administer and interpret the Psychophysical Tests used by DRE’s during the drug influence evaluation.

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• List the vital signs utilized in the DRE examinations

• Check and measure a subject’s vital signs

• List major signs and symptoms of impairment for each drug category

• Conduct eye examinations that are part of the drug influence evaluation

• Describe the history and physiology of alcohol as a drug

Course Learning Objectives (Cont.)

1-6

• Check and measure a subject’s vital signs.

• List the major signs and symptoms of each drug category.

• Conduct the eye examinations that are part of the drug influence evaluation.

• Describe the history and physiology of alcohol as a drug.

Key Points of Emphasis

This two-day school is only the first of three stages in your training as DREs.

Next will come the seven-day formal DRE School.

After that will come several weeks of supervised on-the-job training known as the “Certificate Phase”.

Preview of the remainder of the Pre-School Certification Progress Logs

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• State the goal and objectives of the course

• Define the term “drug” as it is used in the course

• Name the seven categories of drugs and give at least one example of each category

Session Learning Objectives

1-7

Upon successfully completing this session the participant will be able to:

• State the goal and objectives of the course.

• Define the term “drug” as it is used in the course.

• Name the seven categories of drugs and give at least one example of each category.

CONTENT SEGMENTS LEARNING ACTIVITIES

A. Welcoming Remarks and Objectives Instructor-Led Presentations

B. Definition and Categories of Drugs

B. Definition and Categories of Drugs

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• Webster’s Seventh New Collegiate Dictionary

• Random House College Dictionary

Drug Definition

1-8

Alternative Definitions, drawn from Several Sources

“a substance used as a medicine or in making medicines.”

Source: Webster’s Seventh New Collegiate Dictionary, 1971 edition.

“a narcotic substance or preparation.”

Source: Webster’s. Ask participants if they agree that all drugs are narcotics.

“a chemical substance administered to a person or animal to prevent or cure disease or otherwise to enhance physical or mental welfare.”

Source: Random House College Dictionary, 1982 edition.

“a habit-forming medicinal substance, especially a narcotic.”

Source: Random House.

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• Medical Dictionary For the Non-Professional

• Los Angeles Police Department Drug Recognition Training

• LAPD

Drug Definition (Cont.)

1-9 “a substance taken by mouth, injected or applied locally to treat a disorder (i.e., to ease pain).”

“a chemical substance introduced into the body to cause pleasure or a sense of changed awareness, as in the non-medical use of Lysergic Acid Diethylamide (LSD).

Source: Medical Dictionary For the Non-Professional, Barrows Educational Series, Inc., Woodbury, NY. 1984.

“any substance, natural or artificial that by chemical nature alters the structure or function of a living organism.”

Source: Los Angeles Police Department Drug Recognition Training, May 1986.

“any substance that, in small amounts, produces changes in the body, mind or both.”

Source: LAPD

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“Any substance that, when taken into the human body, can impair the ability of the

person to operate a vehicle safely”

DRE Working Definition of “Drug”

1-10

A Simple, Enforcement-Oriented Definition of Drugs

“any substance that, when taken into the human body, can impair the ability of the person to operate a vehicle safely.”

Working definition derived from the 1985 California Vehicle Code. Within this simple, enforcement-oriented definition, there are seven categories of drugs.

Each category consists of substances that impair a person’s ability to drive.

The categories differ from one another in terms of how they impair driving ability and in terms of the kinds of impairment they cause.



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“Any substance that, when taken into the human body, can impair the ability of the

person to operate a vehicle safely”

DRE Working Definition of “Drug” (Cont.)

1-11

• Because the categories produce different types of impairment, they generate different signs and symptoms.

• With training and practice, you will be able to recognize the different signs of drug influence and determine which category is causing the impairment you observe in a subject.

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• Barbiturates

• Alcohol

• Valium

• Chloral Hydrate

Central Nervous System Depressants

1-12

Central Nervous System Depressants

The category of CNS Depressants includes some of the most commonly abused drugs.

Alcohol – the most familiar drug of all – is abused by an estimated 40-50 million Americans.

• Slightly more than half of Americans age 12 or older reported being current drinkers of alcohol in 2010 (51.8% of the population). This translates to an estimated 131 million people. Source: National Survey on Drug Use and Health (NSDUH, 2010)

• Depressant drugs consistently rank among the most widely used and abused drugs in the U.S. and Canada. Over the past decade, an estimated 60 million prescriptions were processed for minor tranquilizers in U.S. pharmacies. Source: Downers: A New Look at Depressant Drugs

Depressants slow down the operation of the central nervous system (i.e., the brain, brain stem and spinal cord).

• Cause the user to react more slowly.

• Cause the user to process information more slowly.

• Relieve anxiety and tension.

• Induce sedation, drowsiness and sleep.

• In high enough doses, CNS depressants will produce general anesthesia, i.e. depress the brain’s ability to sense pain. In very high doses, induce coma and death.

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• Cocaine

• Amphetamines

• Methamphetamine

Central Nervous System Stimulants

1-13

Central Nervous System Stimulants

CNS Stimulants are a widely abused category of drugs.

• In 2008, 20.8 million Americans aged 12 or older (8.8 percent of persons in that age group) had used prescription type stimulants non-medically at least once in their lifetime. Source: National Survey on Drug Use and Health (NSDUH), 2011.

• In 2011, there were 1.4 million cocaine users aged 12 or older comprising 0.5 percent of the U.S. population. Source: NSDUH Report, 2011.

CNS Stimulants speed up the operation of the central nervous system, and of the various bodily functions controlled by the central nervous system.

• Cause the user to become hyperactive, extremely talkative.

• Speech may become rapid and repetitive.

• Heart rate increases.

• Blood pressure increases.



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• Cocaine

• Amphetamines

• Methamphetamine

Central Nervous System Stimulants (Cont.)

1-14

• Body temperature rises, user may become excessively sweaty.

• Induce emotional excitement, restlessness, irritability.

• Can induce cardiac arrhythmia (unstable beating of the heart), cardiac seizures and death.

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• LSD

• Peyote

• Ecstasy

Hallucinogens

1-15

Hallucinogens

Hallucinogens are also widely abused. In recent years an increase in the abuse of LSD, Ecstasy (MDMA), and many new hallucinogens has been reported. • It is estimated that approximately one million Americans abuse hallucinogens.

• Hallucinogens may create hallucinations. That is, they may create apparent perceptions of things not truly present.

• Hallucinogens may also create very distorted perceptions, so that the user sees, hears and smells things in a way quite different from how they really look, sound and smell.

Instead, Hallucinogens cause the nervous system to send strange or false signals to the brain.

• Produce sights, sounds and odors that aren’t real.

• Induce a temporary condition very much like psychosis or insanity.

• Can create a “mixing” of sensory modes, for example, the user “hears colors,” “sees music,” “tastes sounds,” etc., referred to as “Synesthesia.”

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• Phencyclidine (PCP)

• Ketamine

• Dextromethorphan (DXM)

Dissociative Anesthetics

1-16


This category includes drugs such as PCP, its analogs and Dextromethorphan (DXM). These drugs generally inhibit pain by cutting off or “dissociating” the brain’s perception of the pain.

The medical community considers PCP to be a Hallucinogen. However, because of the symptomatology PCP presents, it is included in this category.

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Dissociative Anesthetics – PCP

1-17

PCP is a synthetic drug, i.e., it does not occur naturally but must be produced in a laboratory-like setting.

PCP is similar to CNS depressants in that it depresses brain wave activity.

• Slows down thought.

• Slows reaction time.

• Slows verbal responses.

But PCP is similar to CNS stimulants in that it activates the parts of the brain that control emotions, the heart and the other autonomic systems.

• Heart rate increases.

• Blood pressure increases.

• Adrenalin production increases.

• Body temperature rises.

• Muscles become rigid.

And PCP is similar to hallucinogens in that it distorts or “scrambles” signals received by the brain.

• Sight, hearing, taste, smell and touch may all be distorted.

• User’s perception of time and space may be distorted.

• User may become paranoid, feel isolated and depressed.

• User may develop a strong fear of and pre-occupation with death.

• User may become unpredictably violent.

PCP analogs include Ketamine, Ketalar, Ketajet and Ketaset.

Dextromethorphan (DXM) is an ingredient found in numerous over-the-counter cough and cold remedies.

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• Heroin

• Morphine

• Codeine

Narcotic Analgesics

1-18

Narcotic Analgesics

There are two subcategories of Narcotic Analgesics:

• Opiates are derivatives of Opium.

• Synthetics are produced chemically in the laboratory. They are not in any way derived from Opium but produce similar effects.

The word “Analgesic” means pain reliever. All of the drugs in this category reduce the person’s reaction to pain.

• According to the 2008 National Survey on Drug Use and Health report, approximately 1.5% of Americans have used heroin, however, those numbers are growing.

• Heroin is highly addictive.

• Many addicts support their habit by stealing property and converting it to cash.

In addition to reducing pain, they produce euphoria, drowsiness, apathy, lessened physical activity and sometimes impaired vision.

Persons under the influence of Narcotic Analgesics often pass into a semi-conscious type of sleep or near sleep. • Persons “on the nod” may be awakened easily.

• They often are sufficiently alert to respond to questions effectively.

Higher doses of Narcotic Analgesics can induce coma, respiratory failure and death.

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• Paint

• Glue

• Nitrous Oxide

Inhalants

1-19

Inhalants

Inhalants are fumes of certain substances that produce mind altering results.

There are three subcategories of inhalants:

• Volatile solvents (e.g., gasoline, glue, oil-based paint, cleaning fluids, paint remover, etc.)

• Aerosols (i.e., the propellant gases in spray cans, e.g., hair sprays, insecticides, etc.)

• Anesthetic Gases (e.g., nitrous oxide, ether, amyl nitrite, butyl nitrate, etc.)

Different inhalants produce different effects.

• Many produce effects similar to those of CNS depressants.

• A few produce stimulant like effects.

• Some produce hallucinogenic effects.

The inhalant abuser’s attitude and demeanor can vary from inattentive, stuporous and passive to irritable, violent and dangerous.

The abuser’s speech will often be slow, thick and slurred.

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• Marijuana

• Hashish

• Marinol

• K-2 / Spice

Cannabis

1-20

Cannabis

The category “Cannabis” includes the various forms and products of the Cannabis Sativa plant.

The active ingredient in Cannabis is the substance known as “Delta-9 Tetrahydrocannabinol,” or “THC.”

Apart from alcohol, marijuana is one of the most commonly abused drugs.

Marijuana continues to be the most used illegal drug in the U.S. with 17.4 million Americans over the age of 12 reporting use in the past month. Source: NSDUH, 2010.

Cannabis appears to interfere with the attention process. Drivers under the influence of marijuana often do not pay attention to their driving.

Cannabis also produces a distortion of the user’s perception of time, an increased heart rate (often over 100 beats per minute) and a reddening of the conjunctiva.

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• According to the NSDUH, 2011 18.1 million Americans aged 12 or older used marijuana at least once in the month prior to being surveyed

• Approximately 6.9 percent of the U.S. population admitted using marijuana on a regular basis (SAMHSA, 2010)

• In 2011, 22.5 million Americans aged 12 or older were current illicit drug users

Frequency of Drug Use

1-21

Frequency of Drug Use

• According to the National Survey on Drug Use and Health, 2011, 18.1 million Americans aged 12 or older used marijuana at least once in the month prior to being surveyed.

• Approximately 6.9 percent of the U.S. population admitted using marijuana on a regular basis (SAMHSA, 2011).

• In 2011, an estimated 22.5 million Americans aged 12 or older were current illicit drug users. Source: National Survey on Drug Use and Health (NSDUH, 2011).

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• In 2011 approximately 6.1 million people aged 12 years or older used psychotherapeutic drugs non-medically (NSDUH, 2011).

Frequency of Drug Use (Cont.)

1-22

• In 2011, approximately 6.1 million people aged 12 years or older used psychotherapeutic drugs non-medically.

Source: National Survey on Drug Use and Health (NSDUH, 2010).

• The exact number of prescription drug users in the U.S. is unknown. However, in 2011 a record 4 billion drug prescriptions were written in the U.S.

Source: Medical News Today, September 18, 2012.

• Among those aged 50 to 59, the rate of past month illicit drug use increased from 2.7 percent in 2002 to 5.8 percent in 2010. This trend may partially reflect the aging into this age group of the “Baby Boomer” generation, whose lifetime rate of illicit drug use is higher than those of older cohorts.

• Approximately 6.0 million Americans abuse prescription drugs each year.

Source: NSDUH Report, 2010.

• In 2010, 10.6 million persons aged 12 or older reported driving under the influence of illicit drugs during the past year. This corresponds to 4.0 percent of the population aged 12 or older. In 2010, the rate was highest among young adults aged 18 to 25 (12.7 percent).

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Frequency of Polydrug Use

1-23

• Though drug evaluation subjects may be under the influence of any one of the mentioned categories of drugs, it is not uncommon to find individuals who have taken several combinations of drugs

• Data being collected through the national DRE Database indicates that approximately 35% of all toxicology results indicate two or more drug categories

• The term “polydrug” use refers to instances where the subject has ingested drugs from two or more drug categories

Polydrug Use

• Though drug evaluation subjects may be under the influence of any one of the mentioned categories of drugs, it is not uncommon to find individuals who have taken several combinations of drugs.

• Data being collected through the national DRE Database indicates that approximately 35% of all toxicology results indicate two or more drug categories.

• The term “polydrug” use refers to instances where the subject has ingested drugs from two or more drug categories.

• Most controlled prescription drug abusers are polydrug abusers. One study reported that approximately 75% of persons who abuse alcohol also abuse illicit drugs. Source: “Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the U.S.,” National Center on Addiction and Substance Abuse, July 2005.



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QUESTIONS?

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DRUG EVALUATION AND CLASSIFICATION PROGRAM

GLOSSARY OF TERMS

ACCOMMODATION REFLEX

The adjustment of the eyes for viewing at various distances. Meaning the pupils will automatically constrict as objects move closer and dilate as objects move further away.

ADDICTION

Habitual, psychological, and physiological dependence on a substance beyond one’s voluntary control.

ADDITIVE EFFECT

One mechanism of polydrug interaction. For a particular indicator of impairment, two drugs produce an additive effect if they both affect the indicator in the same way. For example, cocaine elevates pulse rate and PCP also elevates pulse rate. The combination of cocaine and PCP produces an additive effect on pulse rate.

AFFERENT NERVES

See: "Sensory Nerves."

ALKALOID

A chemical that is found in, and can be physically extracted from, some substance. For example, morphine is a natural alkaloid of opium. It does not require a chemical reaction to produce morphine from opium.

ANALGESIC

A drug that relieves or allays pain.

ANALOG (of a drug)

An analog of a drug is a chemical that is very similar to the drug, both in terms of molecular structure and in terms of psychoactive effects. For example, the drug Ketamine is an analog of PCP.

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ANESTHETIC

A drug that produces a general or local insensibility to pain and other sensation.

ANTAGONISTIC EFFECT

One mechanism of polydrug interaction. For a particular indicator of impairment, two drugs produce an antagonistic effect if they affect the indicator in opposite ways. For example, heroin constricts pupils while cocaine dilates pupils. The combination of heroin and cocaine produces an antagonistic effect on pupil size. Depending on how much of each drug was taken, and on when they were taken, the suspect's pupils could be constricted, or dilated, or within the DRE Average range of pupil size.

ARRHYTHMIA

An abnormal heart rhythm.

ARTERY

The strong, elastic blood vessels that carry blood away the heart.

ATAXIA

A blocked ability to coordinate movements. A staggering walk and poor balance may be caused by damage to the brain or spinal cord. This can be the result of trauma, birth defect, infection, tumor, or drug use.

AUTONOMIC NERVE

A motor nerve that carries messages to the muscles and organs that we do not consciously control. There are two kinds of autonomic nerves, the sympathetic nerves and parasympathetic nerves.

AXON

The part of a neuron (nerve cell) that sends out a neurotransmitter.

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BAC

(Blood Alcohol Concentration) - The percentage of alcohol in a person’s blood.

BrAC

(Breath Alcohol Concentration) - The percentage of alcohol in a person’s blood as measured by a breath testing device.

BLOOD PRESSURE

The force exerted by blood on the walls of the arteries. Blood pressure changes continuously, as the heart cycles between contraction and expansion.

BRADYCARDIA

Abnormally slow heart rate.

BRADYPNEA

Abnormally slow rate of breathing.

BRUXISM

Grinding the teeth. This behavior is often seen in person who are under the influence of cocaine or other CNS Stimulants.

CANNABIS

This is the drug category that includes marijuana. Marijuana comes primarily from the leaves of certain species of Cannabis plants that grow readily all over the temperate zones of the earth. Hashish is another drug in this category, and consists of the compressed leaves from female Cannabis plants. The active ingredient in both Marijuana and Hashish is a chemical called delta-9 tetrahydrocannabinol, usually abbreviated THC.

CARBOXY THC

A metabolite of THC (tetrahydrocannabinol).

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CHEYNE- STOKES RESPIRATION

Abnormal pattern of breathing. Marked by breathlessness and deep, fast breathing.

CNS (Central Nervous System)

A system within the body consisting of the brain, the brain stem, and the spinal cord.

CNS DEPRESSANTS

One of the seven drug categories. CNS Depressants include alcohol, barbiturates, anti-anxiety tranquilizers, and numerous other drugs.

CNS STIMULANTS

One of the seven drug categories. CNS Stimulants include Cocaine, the Amphetamines, Ritalin, Desoxyn, and numerous other drugs.

CONJUNCTIVITIS

An inflammation of the mucous membrane that lines the inner surface of the eyelids caused by infection, allergy, or outside factors. May be bacterial or viral. Persons suffering from conjunctivitis may show symptoms in one eye only. This condition is commonly referred to as "pink eye", a condition that could be mistaken for the bloodshot eyes produced by alcohol or Cannabis.

CONVERGENCE

The "crossing" of the eyes that occurs when a person is able to focus on a stimulus as it is pushed slowly toward the bridge of their nose. (See, also, "Lack of Convergence".)

CRACK/ROCK

Cocaine base, appears as a hard chunk form resembling pebbles or small rocks. It produces a very intense, but relatively short duration "high".

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CURRICULUM VITAE

A written summary of a person's education, training, experience, noteworthy achievements and other relevant information about a particular topic.

CYCLIC BEHAVIOR

A manifestation of impairment due to certain drugs, in which the suspect alternates between periods (or cycles) of intense agitation and relative calm. Cyclic behavior, for example, sometimes will be observed in persons under the influence of PCP.

DELIRIUM

A brief state characterized by incoherent excitement, confused speech, restlessness, and possible hallucinations.

DENDRITE

The part of a neuron (nerve cell) that receives a neurotransmitter.

DIACETYL MORPHINE

The chemical name for Heroin.

DIASTOLIC

The lowest value of blood pressure. The blood pressure reaches its diastolic value when the heart is fully expanded, or relaxed (Diastole).

DIPLOPIA

Double vision.

DISSOCIATIVE ANESTHETICS

One of the seven drug categories. Includes drugs that inhibits pain by cutting off or disassociating the brain's perception of pain. PCP and its analogs are considered Dissociative Anesthetics.

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DIVIDED ATTENTION

Concentrating on more than one thing at a time. The four psychophysical tests used by DREs require the suspect to divide attention.

DOWNSIDE EFFECT

An effect that may occur when the body reacts to the presence of a drug by producing hormones or neurotransmitters to counteract the effects of the drug consumed.

DRUG

Any substance that, when taken into the human body, can impair the ability of the person to operate a vehicle safely.

DYSARTHIA

Slurred speech. Difficult, poorly articulated speech.

DYSPNEA

Shortness of breath.

DYSMETRIA

An abnormal condition that prevents the affected person from properly estimating distances linked to muscular movements.

DYSPHORIA

A disorder of mood. Feelings of depression and anguish.

EFFERENT NERVES

See: "Motor Nerves".

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ENDOCRINE SYSTEM

The network of glands that do not have ducts and other structures. They secrete hormones into the blood stream to affect a number of functions in the body.

EXPERT WITNESS

A person skilled in some art, trade, science or profession, having knowledge of matters not within knowledge of persons of average education, learning and experience, may assist a jury in arriving at a verdict by expressing an opinion on a state of facts shown by the evidence and based upon his or her special knowledge. (NOTE: Only the court can determine whether a witness is qualified to testify as an expert.)

FLASHBACK

A vivid recollection of a portion of an hallucinogenic experience. Essentially, it is a very intense daydream. There are three types: (1) emotional -- feelings of panic, fear, etc.; (2) somatic -- altered body sensations, tremors, dizziness, etc.; and (3) perceptual -- distortions of vision, hearing, smell, etc.

GARRULITY

Chatter, rambling or pointless speech. Talkative.

GENERAL INDICATOR

Behavior or observations of the subject that are observed and not specifically tested for. (Observational and Behavioral Indicators)

HALLUCINATION

A sensory experience of something that does not exist outside the mind, e.g., seeing, hearing, smelling, or feeling something that isn't really there. Also, having a distorted sensory perception, so that things appear differently than they are.

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HALLUCINOGENS

One of the seven drug categories. Hallucinogens include LSD, MDMA, Peyote, Psilocybin, and numerous other drugs.

HASHISH

A form of cannabis made from the dried and pressed resin of a marijuana plant.

HASH OIL

Sometimes referred to as “marijuana oil” it is a highly concentrated syrup-like oil extracted from marijuana. It is normally produced by soaking marijuana in a container of solvent, such as acetone or alcohol for several hours and after the solvent has evaporated, a thick syrup-like oil is produced with a high THC content.

HEROIN

A powerful and widely-abused narcotic analgesic that is chemically derived from morphine. The chemical, or generic name of heroin is "diacetyl morphine".

HIPPUS

A rhythmic change in the pupil size of the eyes, as they dilate and constrict when observed in darkness independent of changes in light intensity, accommodation (focusing), or other forms of sensory stimulation. Normally only observed with specialized equipment.

HOMEOSTASIS

The dynamic balance, or steady state, involving levels of salts, water, sugars, and other materials in the body's fluids.

HORIZONTAL GAZE NYSTAGMUS (HGN)

Involuntary jerking of the eyes occurring as the eyes gaze to the side.

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HORMONES

Chemicals produced by the body's endocrine system that are carried through the blood stream to the target organ. They exert great influence on the growth and development of the individual, and that aid in the regulation of numerous body processes.

HYDROXY THC

A metabolite of THC (tetrahydrocannabinol).

HYPERFLEXIA

Exaggerated or over extended motions.

HYPERGLYCEMIA

Excess sugar in the blood.

HYPERPNEA

A deep, rapid or labored breathing.

HYPERPYREXIA

Extremely high body temperature.

HYPERREFLEXIA

A neurological condition marked by increased reflex reactions.

HYPERTENSION

Abnormally high blood pressure. Do not confuse this with hypotension.

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HYPOGLYCEMIA

An abnormal decrease of blood sugar levels.

HYPOPNEA

Shallow or slow breathing.

HYPOTENSION

Abnormally low blood pressure. Do not confuse this with hypertension.

HYPOTHERMIA

Decreased body temperature.

ICE

A crystalline form of methamphetamine that produces a very intense and fairly long-lasting "high".

INHALANTS

One of the seven drug categories. The inhalants include volatile solvents (such as glue and gasoline), aerosols (such as hair spray and insecticides) and anesthetic gases (such as nitrous oxide).

INSUFFLATION

See "snorting".

INTEGUMENTARY SYSTEM

The skin and accessory structures, hair and nails. Functions include protection, maintenance of body temperature, excretion of waste, and sensory perceptions.

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INTRAOCULAR

"Within the eyeball".

KOROTKOFF SOUNDS

A series of distinct sounds produced by blood passing through an artery, as the external pressure on the artery drops from the systolic value to the diastolic value.

LACK OF CONVERGENCE

The inability of a person's eyes to converge, or "cross" as the person attempts to focus on a stimulus as it is pushed slowly toward the bridge of his or her nose.

MAJOR INDICATORS

Physiological signs that are specifically assessed and are, for the most part, involuntary reflecting the status of the central nervous system (CNS) homeostasis (Physiological Indicators)

MARIJUANA

Common term for the Cannabis Sativa plant. Usually refers to the dried leaves of the plant. This is the most common form of the cannabis category.

MARINOL

A drug containing a synthetic form of THC (tetrahydrocannabinol). Marinol belongs to the cannabis category of drugs, but marinol is not produced from any species of cannabis plant.

MEDICAL RULEOUT

A determination made by a DRE that the condition of a suspected impaired driver is more likely related to a medical issue that effected the person’s ability to operate a vehicle safely.

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METABOLISM

The sum of all chemical processes that take place in the body as they relate to the movements of nutrients in the blood after digestion, resulting in growth, energy, release of wastes, and other body functions. The process by which the body, using oxygen, enzymes and other internal chemicals, breaks down ingested substances such as food and drugs so they may be consumed and eliminated. Metabolism takes place in two phases. The first step is the constructive phase (anabolism) where smaller molecules are converted to larger molecules. The second steps is the destructive phase (catabolism) where large molecules are broken down into smaller molecules.

METABOLITE

A chemical product, formed by the reaction of a drug with oxygen and/or other substances in the body.

MIOSIS

Abnormally small (constricted) pupils.

MOTOR NERVES

Nerves that carry messages away from the brain, to be body's muscles, tissues, and organs. Motor nerves are also known as efferent nerves.

MUSCULAR HYPERTONICITY

Rigid muscle tone.

MYDRIASIS

Abnormally large (dilated) pupils.

NARCOTIC ANALGESICS

One of the seven drug categories. Narcotic analgesics include opium, the natural alkaloids of opium (such as morphine, codeine and thebaine), the derivatives of opium (such as heroin, dilaudid, oxycodone and percodan), and the synthetic narcotics.

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NERVE

A cord-like fiber that carries messages either to or from the brain. For drug evaluation and classification purposes, a nerve can be pictured as a series of "wire-like" segments, with small spaces or gaps between the segments.

NEURON

A nerve cell. The basic functional unit of a nerve. It contains a nucleus within a cell body with one or more axons and dendrites.

NEUROTRANSMITTER

Chemicals that pass from the axon of one nerve cell to the dendrite of the next cell, and that carry messages across the gap between the two nerve cells.

NULL EFFECT

One mechanism of polydrug interaction. For a particular indicator of impairment, two drugs produce a null effect if neither of them affects that indicator. For example, PCP does not affect pupil size, and alcohol does not affect pupil size. The combination of PCP and alcohol produces a null effect on pupil size.

NYSTAGMUS

An involuntary jerking of the eyes.

"ON THE NOD"

A semi-conscious state of deep relaxation. Typically induced by impairment due to Heroin or other narcotic analgesics. The suspect's eyelids droop, and chin rests on the chest. Suspect may appear to be asleep, but can be easily aroused and will respond to questions.

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OVERLAPPING EFFECT

One mechanism of polydrug interaction. For a particular indicator of impairment, two drugs produce an overlapping effect if one of them affects the indicator but the other doesn't. For example, cocaine dilates pupils while alcohol doesn't affect pupil size. The combination of cocaine and alcohol produces an overlapping effect on pupil size: the combination will cause the pupils to dilate.

PALLOR

An abnormal paleness or lack of color in the skin.

PARANOIA

Mental disorder characterized delusions and the projection of personal conflicts, that are ascribed to the supposed hostility of others.

PARAPHERNALIA

Drug paraphernalia are the various kinds of tools and other equipment used to store, transport or ingest a drug. Hypodermic needles, small pipes, bent spoons, etc., are examples of drug paraphernalia. The singular form of the word is "paraphernalium". For example, one hypodermic needle would be called a "drug paraphernalium".

PARASYMPATHETIC NERVE

An autonomic nerve that commands the body to relax and to carry out tranquil activities. The brain uses parasympathetic nerves to send "at ease" commands to the muscles, tissues, and organs.

PARASYMPATHOMIMETIC DRUGS

Drugs that mimic neurotransmitter associated with the parasympathetic nerves. These drugs artificially cause the transmission of messages that produce lower blood pressure, drowsiness, etc.

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PDR (Physician's Desk Reference)

A basic reference source for drug recognition experts. The PDR provides detailed information on the physical appearance and psychoactive effects of licitly-manufactured drugs.

PHENCYCLIDINE

A contraction of PHENYL CYCLOHEXYL PIPERIDINE, or PCP. Formerly used as a surgical anesthetic, however, it has no current legitimate medical use in humans.

PHENYL CYCLOHEXYL PIPERIDINE (PCP)

Often called "phencyclidine" or “PCP”, it is a specific drug belonging to the Dissociative Anesthetics category.

PHYSIOLOGY

Physiology is the branch of biology dealing with the functions and activities of life or living matter and the physical and chemical phenomena involved.

PILOERECTION

Literally, "hair standing up", or goose bumps. This condition of the skin is often observed in persons who are under the influence of LSD.

POLYDRUG USE

Ingesting drugs from two or more drug categories.

PSYCHEDELIC

A mental state characterized by a profound sense of intensified or altered sensory perception sometimes accompanied by hallucinations.

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PSYCHOPHYSICAL TESTS

Methods of investigating the mental (psycho-) and physical characteristics of a person suspected of alcohol or drug impairment. Most psychophysical tests employ the concept of divided attention to assess a suspect's impairment.

PSYCHOTOGENIC

Literally, "creating psychosis" or "giving birth to insanity". A drug is considered to be psychotogenic if persons who are under the influence of the drug become insane, and remain so after the drug wears off.

PSYCHOTOMIMETIC

Literally, "mimicking psychosis" or "impersonating insanity". A drug is considered to be psychotomimetic if persons who are under the influence of the drug look and act insane while they are under the influence.

PTOSIS

Droopy eyelids.

PULSE

The expansion and contraction of the walls of an artery, generated by the pumping action of blood.

PULSE RATE

The number of expansions of an artery per minute.

PUPILLARY LIGHT REFLEX

The pupils of the eyes will constrict and dilate depending on changes in lighting.

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PUPILLARY UNREST

The continuous, irregular change in the size of the pupils that may be observed under room or steady light conditions.

REBOUND DILATION

A period of pupillary constriction followed by a period of pupillary dilation where the pupil steadily increases in size and does not return to its original constricted size.

RESTING NYSTAGMUS

Jerking of the eyes as they look straight ahead.

SCLERA

A dense white fibrous membrane that, with the cornea, forms the external covering of the eyeball (i.e., the white part of the eye).

SENSORY NERVES

Nerves that carry messages to the brain, from the various parts of the body, including notably the sense organs(eyes, ears, etc.). Sensory nerves are also known as afferent nerves.

SINSEMILLA

The unpollenated female cannabis plant, having a relatively high concentration of THC.

SFST

Standardized Field Sobriety Testing. There are three SFSTs, namely Horizontal Gaze Nystagmus (HGN), Walk and Turn, and One Leg Stand. Based on a series of controlled laboratory studies, scientifically validated clues of alcohol impairment have been identified for each of these three tests. They are the only Standardized Field Sobriety Tests for which validated clues have been identified.

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SNORTING

One method of ingesting certain drugs. Snorting requires that the drug be in powdered form. The user rapidly draws the drug up into the nostril, usually via a paper or glass tube. Snorting is also known as insufflation.

SPHYGMOMANOMETER

A medical device used to measure blood pressure. It consists of an arm or leg cuff with an air bag attached to a tube and a bulb for pumping air into the bag, and a gauge for showing the amount of air pressure being pressed against the artery.

STETHOSCOPE

A medical instrument used, for drug evaluation and classification purposes, to listen to the sounds produced by blood passing through an artery.

SYMPATHETIC NERVE

An autonomic nerve that commands the body to react in response to excitement, stress, fear, etc. The brain uses sympathetic nerves to send "wake up calls" and "fire alarms" to the muscles, tissues and organs.

SYMPATHOMIMETIC DRUGS

Drugs that mimic the neurotransmitter associated with the sympathetic nerves. These drugs artificially cause the transmission of messages that produce elevated blood pressure, dilated pupils, etc.

SYNAPSE (or Synaptic Gap)

The gap or space between two neurons (nerve cells).

SYNESTHESIA

A sensory perception disorder, in which an input via one sense is perceived by the brain as an input via another sense. An example of this would be a person “hearing” a phone ring and “seeing” the sound as a flash of light. Synesthesia sometimes occurs with persons under the influence of hallucinogens.

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SYSTOLIC

The highest value of blood pressure. The blood pressure reaches its systolic value when the heart is fully contracted (systole), and blood is sent surging into the arteries.

TACHYCARDIA

Abnormally rapid heart rate.

TACHYPNEA

Abnormally rapid rate of breathing.

THC (Tetrahydrocannabinol)

The principal psychoactive ingredient in drugs belonging to the cannabis category.

TOLERANCE

An adjustment of the drug user's body and brain to the repeated presence of the drug. As tolerance develops, the user will experience diminishing psychoactive effects from the same dose of the drug. As a result, the user typically will steadily increase the dose he or she takes, in an effort to achieve the same psychoactive effect.

TRACKS

Scar tissue usually produced by repeated injection of drugs, via hypodermic needle, along a segment of a vein.

VERTICAL GAZE NYSTAGMUS

An involuntary jerking of the eyes (up-and-down) which occurs as the eyes are held at maximum elevation. The jerking should be distinct and sustained.

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VOIR DIRE

A French expression literally meaning “to see, to say.” Loosely, this would be rendered in English as “To seek the truth,” or “to call it as you see it.” In a law or court context, one application of voir dire is to question a witness to assess his or her qualifications to be considered an expert in some matter pending before the court.

VOLUNTARY NERVE

A motor nerve that carries messages to a muscle that we consciously control.

WITHDRAWAL

This occurs in someone who is physically addicted to a drug when he or she is deprived of the drug. If the craving is sufficiently intense, the person may become extremely agitated, and even physically ill.

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Participant Manual DRE Pre School - Session 2 – Observation of the Eyes and Additional Tests for Drug Impairment

Session 2 – Overview of the Drug Evaluation and Classification Procedures

Preliminary Training for Drug Evaluation and Classification Program

Session 2

Overview of the Drug Evaluation and Classification Procedures

60 Minutes


• Identify the 12 components of the DRE drug influence evaluation.

• Discuss the purposes of each component.


A. Components of the Process Instructor-Led Presentations B. Video/DVD Demonstrations Video/DVD Presentations

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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A Systematic and Standardized Method

The Drug Influence Evaluation

2-3

A. Components of the Process

The Drug Influence Evaluation

The Drug Evaluation and Classification Process is a systematic and standardized method of examining a subject to determine:

• Whether the subject is impaired by a drug or combination of drugs.

• If the impairment is resulting from an injury, illness, or drug related.

• The category (or categories) of drugs that is (or are) the likely cause of the subject’s impairment.

The process is systematic in that it is based on a careful assessment of a variety of observable signs and symptoms that are known to be reliable indicators of drug impairment.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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• Appearance

• Behavior

• Psychophysical Testing

The Systematic Process

2-4

Some of these observable signs and symptoms relate to the subject’s appearance.

Some of the signs and symptoms relate to the subject’s behavior.

Some relate to the subject’s performance of carefully administered psychophysical tests.

• Drugs impair the subject’s ability to control his or her mind and body.

• Psychophysical tests can disclose that the subject’s ability to control mind and body is impaired.

• The specific manner in which the subject performs the psychophysical tests may indicate the type of impairment from which the subject is suffering. In turn, this may indicate the category or categories of drugs causing the impairment.

Some of the observable signs and symptoms relate to automatic responses of the subject’s body to the specific drugs that are present.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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• Autonomic responses of the body

• Standardization of evaluation

Components of the Process

2-5

All of these reliable indicators are examined and carefully considered before a judgment is made concerning what categories of drugs are affecting the subject. The process is standardized in that it is administered the same way, to every subject, by every drug recognition expert.

• Standardization helps to ensure that no mistakes are made.

• No examinations are left out.

• No extraneous or unreliable “indicators” are included.

• Standardization helps to promote professionalism among drug recognition experts.

• Standardization helps to secure acceptance in court


Preliminary Training for Drug Evaluation and Classification Program 2-6

12 Step Process

12 Step Process

The Drug Evaluation and Classification process has twelve components or steps.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Breath Alcohol Test

Step 1

2-7

Breath Alcohol Test

Breath Alcohol Test to determine Blood Alcohol Concentration (BAC).

• The purpose of the breath test is to determine whether the specific drug, alcohol, may be contributing to the impairment observable in the subject.

• Obtaining an accurate measurement of BAC enables the DRE to assess whether alcohol may be the sole cause of the observable impairment, or whether it is likely that some other drug or drugs, or other complicating factors are contributing to the impairment.



Interview of the Arresting Officer

Step 2

2-8

Interview of the Arresting Officer

• In most cases, the subjects you will examine will not be people that you arrested.

• The arresting officer may have seen or heard things that would be valuable indicators of the kinds of drugs the subject has ingested.

• The arresting officer, in searching the subject, may have uncovered drug related paraphernalia, or even drugs themselves.

• The arresting officer also may be able to alert you to important information about the subject’s behavior that could be very valuable for your own safety.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Preliminary ExaminationStep 3

2-9

Preliminary Examination

• The preliminary examination is your first opportunity to observe the subject closely and directly.

• A major purpose of the preliminary examination is to determine if the subject may be suffering from an injury or some other medical condition not necessarily related to drugs.

Analogy: The preliminary examination is a “fork in the road.” It can help you decide whether to continue with the drug evaluation, or to pursue a possible medical complication, or to proceed with a DWI (alcohol) case.

Another major purpose of the preliminary examination is to begin systematically assessing the subject’s appearance, behavior and automatic bodily responses for signs of drug-induced impairment.

The preliminary examination consists of a series of questions dealing with possible injuries or medical problems; observations of the subject’s face, speech and breath; initial checks of the subject’s eyes; and, an initial examination of the subject’s pulse.

The initial examination of the eyes may reveal signs of injury or illness. A difference in pupil size of greater than 0.5 mm may indicate an injury or existing medical condition.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Examination of the Eyes

Step 4

2-10

HGN Right Eye Left Eye Vertical Gaze Nystagmus?

Lack of Smooth PursuitYes No

Max. Deviation ConvergenceRight Eye Left Eye

Angle of Onset

Examinations of the Eyes

This is the time when DRE’s will administer three tests of the subject’s eyes; Horizontal Gaze Nystagmus, Vertical Gaze Nystagmus and Lack of Convergence. Certain drugs produce very easily observable effects on the eyes.

• One of the most dramatic of these effects is nystagmus, which means an involuntary jerking of the eyes.

• Persons under the influence of alcohol usually will exhibit Horizontal Gaze Nystagmus, which is an involuntary jerking of the eyes as the eyes gaze to the side.

• Alcohol is not the only drug that causes nystagmus.

• Horizontal Gaze Nystagmus is not the only observable effect on the eyes that will be produced by various drugs.



Divided Attention Tests

Step 5

2-11

Cannot keep balance___________Starts too soon _______________

Stops WalkingMisses Heel-ToeSteps Off LineRaises ArmsActual Steps Taken

1st Nine 2nd Nine

Walk And Turn Test

Describe Turn Cannot Do Test (explain)

Right LeftDraw lines to spots touched

2

4

5

1

3

6

Balance Eyes Closed

Internal Clock:______Estimated as 30 sec.

One Leg Stand:

Sways while balancing.Uses arms to balance.Hopping.Puts foot down.

L R

Type of Footwear

Divided Attention Psychophysical Tests All drugs that impair driving ability will also impair the subject’s ability to perform certain carefully designed divided attention tests.

These tests are familiar to you in the context of examining alcohol impaired subjects. • The same tests are very valuable for disclosing evidence of impairment due to drugs

other than alcohol.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Examination of Vital Signs

Step 6

2-12

Pulse & Time

1. ________bpm / __________

2. ________bpm / __________

3. ________bpm / __________

Blood Pressure Temp

_____ /_____mmHg ________

Examination of Vital Signs

Many categories of drugs affect the operation of the heart, lungs and other major organs of the body.

These effects show up during examination of the subject’s vital signs.

• The vital signs that are reliable indicators of drug influence include blood pressure, pulse, and temperature.

• Blood pressure is measured with two medical instruments; a stethoscope and a sphygmomanometer.



Darkroom Examinations

Step 7

2-13

Pupil Size Room Light Darkness Direct Nasal Area

Left Eye

Right Eye

Rebound DilationYes No

Reaction to Light

Oral Cavity

Dark Room Examinations

Many categories of drugs affect how the pupils of the eyes will appear, and how they respond to light.

• Certain kinds of drugs will cause the pupils to grow larger, or dilate.

• Some other drugs cause the pupils to be smaller, or constrict.

By systematically changing the amount of light entering the subject’s eyes, we can observe the pupils’ appearance and reaction under controlled conditions.

We carry out these examinations in a dark room, using a penlight to control the amount of illumination entering the subject’s eyes. We use a device called a pupillometer to estimate the size of the subject’s pupils.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Darkroom Examinations (Cont.)

Step 7

2-14

Pupil Size Room Light Darkness Direct Nasal Area

Left Eye

Right Eye

Rebound DilationYes No

Reaction to Light

Oral Cavity

Other examinations are also conducted in the darkroom, using the penlight: i.e., examination of the nasal area and mouth for signs of drug use and for concealed contraband.



Examination for Muscle Tone

Step 8

2-15

MUSCLE TONE:Near Normal Flaccid Rigid

Comments:

Examination of Muscle Tone

Certain categories of drugs can cause the user’s muscles to become markedly tense, and rigid, while others can cause the muscles to be very flaccid, or loose and rubbery.

Evidence of muscle tone may come to light when the subject attempts to perform the divided attention test.

Evidence of muscle tone can also be observed when taking the subject’s pulse and blood pressure.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Examination for Injection Sites

Step 9

2-16

RIGHT ARM LEFT ARM

ATTACH PHOTOS OF FRESH PUNCTURE MARKS

Examination for Injection Sites

Certain drugs are commonly injected by their users via hypodermic needles.

Heroin is probably most commonly associated with injection, but several other types of drugs also are injected by many users.

Uncovering injection sites on a subject provides powerful evidence that he or she may be under the influence of specific types of drugs.



Suspect’s Statements and Other Observations

Step 10

2-17

What medicine or drug have you been using? How much? Time of use? Where were the drugs used? (Location)

Date/Time of Arrest Time DRE Notified Eval. Start Time Time Completed

Member Signature (Include Rank) ID No. Reviewed By

Opinion of Evaluator: Rule Out Alcohol Stimulant D/A InhalantMedical Depressant Hallucinogen Narcotic Analgesic Cannabis

Suspect’s Statements and Other Observations

At this point in the evaluation, the trained DRE should have reasonable grounds to believe that the subject is under the influence of a drug or drugs.

The DRE should also have at least an articulable suspicion as to the category or categories of drugs causing the impairment.

The DRE should proceed to interview the subject to confirm his or her suspicion/opinions concerning the drug or drugs involved.

The DRE must carefully record the subject’s statements and any other observations that may constitute relevant evidence of drug induced impairment.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Opinion of the Evaluator

Step 11

2-18

Opinion of the Evaluator

Based on all of the evidence and observations gleaned from the preceding ten steps, the DRE must reach an informed conclusion as to:

Whether the subject is under the influence of a drug or drugs.

If so, the probable category or categories of drugs causing the impairment.

The DRE must record a narrative summary of the facts forming the basis for his or her conclusions.



Toxicological Examination

Step 12

2-19

Toxicological Examination

The toxicological examination is a chemical test or tests designed to obtain scientific, admissible evidence to substantiate the DRE’s conclusions.

Departmental policy and procedures must be carefully and completely followed in requesting, obtaining and handling the chemical sample.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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1. Breath alcohol test2. Interview of arresting officer (Note:

gloves must be worn from this point on)

3. Preliminary examination and first pulse4. Eye Examinations5. Divided attention tests:

• Modified Romberg Balance• Walk and Turn• One Leg Stand• Finger to Nose

Drug Influence Evaluation Checklist

2-20

Review of Drug Influence Evaluation Checklist



6. Vital signs and second pulse7. Dark room examinations and ingestion

examination8. Check for muscle tone9. Check for injection sites and third pulse10. Interrogation, statements and other

observations11. Opinion of evaluator12. Toxicological examination

Drug Influence Evaluation Checklist (Cont.)

2-21

B. Video Demonstrations



QUESTIONS?

2-22

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Drug Influence Evaluation Checklist

_____ 1. Breath Alcohol Test

_____ 2. Interview of Arresting Officer (NOTE: Gloves must be worn from this point on)

_____ 3. Preliminary Examination

-first pulse, initial estimation of angle of onset, and initial estimation of pupil size

_____ 4. Eye Examination

_____ 5. Divided Attention Tests: _____ Romberg Balance _____ Walk and Turn _____ One Leg Stand _____ Finger to Nose

_____ 6. Vital signs and Second Pulse

_____ 7. Dark Room Check of Pupil Size and Ingestion Exam

_____ 8. Check of Muscle Tone

_____ 9. Check for Injection Sites and Third Pulse

_____ 10. Interrogation, Statements, and Other Observations

_____ 11. Opinion of Evaluator

_____ 12. Toxicological Examination

HS 172A R5/13

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Participant Manual DRE Pre School - Session 3 – Psychophysical Tests

Session 3 – Psychophysical Tests


Session 3

Psychophysical Tests

90 Minutes



• Administer the four divided attention tests used in the drug influence evaluation process

• Document the subject’s performance of those tests

Learning Objectives

3-2


• Administer the four divided attention tests used in the drug influence evaluation process.

• Document the subject’s performance of those tests.


A. Modified Romberg Balance Test Instructor-Led Presentations B. Walk and Turn Participant-Led Demonstrations C. One Leg Stand Hands-on Practice D. Finger to Nose

• Four divided attention psychophysical tests are administered in the DRE evaluation – Modified Romberg Balance Test, Walk and Turn, One Leg Stand and Finger to Nose.

• The Walk and Turn and One Leg Stand as well as HGN have been scientifically validated by conducting controlled research to demonstrate their reliability. The Modified Romberg Balance Test and Finger to Nose have not been subjected to that sort of scrutiny; however, if properly administered and recorded they are very credible evidence of impairment.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Modified Romberg Balance Test Diagram

3-3

Modified Romberg Balance

Internal Clock:_____Estimated as 30 sec.

Approx. Approx.

A. Modified Romberg Balance Test

The Modified Romberg Balance Test is the first divided attention test that is administered during the drug influence evaluation.

• The test requires the subject to stand with the feet together and the head tilted back slightly and with the eyes closed.

• The test also requires that the subject attempt to estimate 30 seconds; the subject must be instructed to open the eyes and tilt the head forward and say “stop” when they think thirty seconds has elapsed.



30 Seconds

3-4

• Internal timing estimate

• Some drugs tend to speed up or slow down the subject’s internal clock

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Modified Romberg Balance Test

3-5

• Divided attention

• Internal Clock

• The DRE must record how much time actually elapsed from the start of the test until the subject opened the eyes.

• If the subject continues to keep the eyes closed for 90 seconds, the DRE should stop the test and record the fact that it was terminated at 90 seconds.



Modified Romberg Balance Test Administration

3-6

• Tell the subject to stand straight with the feet together and the arms down at the sides

• Tell the subject to maintain that position while you give the instructions (Ask the subject if he or she understands so far)

• Tell the subject when you instruct them to begin the test, they must tilt their head back and close their eyes

• Tell the subject that when you say "Start", they must keep their head tilted back with their eyes closed until they think that 30 seconds have gone by

• Tell the subject that, when they think the 30 seconds have gone by, they must bring their head forward, open their eyes, and say "Stop"

Administrative Procedures and Instructions

• Tell the subject to stand straight with the feet together and the arms down at the sides.

• Tell the subject to maintain that position while you give the instructions. Emphasize that he or she must not start the test until told to start.

• Ask the subject if he or she understands so far.

• Tell the subject when you instruct them to begin the test, they must tilt their head back and close their eyes.

• Tell the subject that when you say "Start", they must keep their head tilted back with their eyes closed until they think that 30 seconds have gone by. DO NOT tell the subject to "count to thirty seconds" or to use any other specific procedure to keep track of time. But on the other hand, DO NOT tell the subject that they are not allowed to count to thirty seconds. SIMPLY SAY, "keep your head tilted back with your eyes closed until you think that thirty seconds have gone by".

• Tell the subject that, when they think the 30 seconds have gone by, they must bring their head forward, open their eyes, and say "Stop".

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Modified Romberg Balance Test Administration (Cont.)

3-7

• Ask the subject if they understand• Look at your timing device and pick a convenient time

to start the test• Tell the subject to tilt their head back and close their

eyes• Tell the subject to begin or start the test• Keep track of time while the subject performs the test• When the subject opens the eyes, ask them "how much

time was that?"• If 90 seconds elapse before the subject opens their

eyes, stop the test

• Ask the subject if they understand.

• Look at your timing device and pick a convenient time to start the test.

• Tell the subject to tilt their head back and close their eyes.

• Tell the subject to begin or start the test.

• Keep track of time while the subject performs the test.

• When the subject opens the eyes, ask them "how much time was that?"

• If 90 seconds elapse before the subject opens their eyes, stop the test.

• Instructor-to-instructor demonstrations.

• Instructor-to-participant demonstration.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Modified Romberg Balance Test Demonstrations

3-8



12 2 1

Participant-Led Demonstrations

The major items that need to be recorded for the Modified Romberg Balance test are:

• The amount that the subject sways.

• The actual amount of time that the subject keeps the eyes closed.

• To record swaying, the DRE must estimate how many inches the subject sways, either front-to-back or left-to-right, or both.

Example: If the subject sways approximately two inches toward the left and approximately two inches toward the right, the DRE should write the number “2” on each side of the “stick figure” that shows left-to-right movement. To record the subject’s time estimate, simply write the number of seconds that the subject kept his or her eyes closed.



Modified Romberg Balance Test Practice

3-9



Hands-On Practice

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Walk and Turn Test

3-10

B. Walk and Turn

Walk and Turn is the second divided attention test administered during the drug influence evaluation.

The test is administered the same way that we have used it for Standardized Field Sobriety Testing purposes.

• Monitor the practice and offer coaching and constructive criticism, as appropriate. • Review of Walk and Turn administrative procedures.

The test has two stages: the instructions stage and the walking stage.

• During the instructions stage the subject must stand heel-to-toe, with the right foot ahead of the left foot with the heel of the right foot against the toe of the left foot, and keeping the arms at the sides.

• Demonstrate the stance that the subject must maintain during the instructions stage. If the subject fails to maintain the starting position during your instructions, discontinue the instructions and direct the subject back to the starting position before continuing.

• The subject is told to not start walking until told to do so.

• The subject must be told to take nine heel-to-toe steps on the line, to turn around keeping the front or lead foot on the line and to turn by taking a series of small steps with the other foot, and to return nine heel-to-toe steps down the line.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 7 of 17



Walk and Turn Test Diagram

3-11



1st Nine 2nd NineWalk And Turn Test


• The subject must be told to watch his or her feet while walking, and to count the steps out loud.

• The subject must be told to keep their arms at the sides at all times.

• The subject must be told not to stop walking until the test is completed.

• The subject should be asked if he/she understands the instructions.

• Once the subject acknowledges his/her understanding of the instructions, instruct the subject to begin the test.

• If the subject stops or fails to count out loud or watch his/her feet, remind him/her to perform these tasks. This interruption will not affect the validity of the test and is essential for evaluating divided attention.



Walk and Turn Test

3-12

• Instructor – Participant demonstration

• Participant – Participant demonstration

Instructor-to-participant demonstration Participant-to-Participant Demonstration

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Walk and Turn Recording Results

3-13





Recording Results of the Walk and Turn Test

• We record the very same clues on this test that we use for Standardized Field Sobriety Testing purposes.

Instruction stage clues:

• Cannot maintain balance while listening to instructions (feet break away from the heel-to-toe stance). Draw a slash mark at an angle in the direction the subject stepped out of the instruction position.

• Starts too soon (i.e., subject starts walking before told to do so).

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Walk and Turn Test Diagram

3-14

M S

Walking stage clues:

• Stops while walking

• Does not touch heel-to-toe (distance ½”)

• Steps off the line

• Uses arms to balance (distance 6”)

• Improper turn

• Incorrect number of steps

During the walking stage, clues should be marked in the following manner:

• On the lines indicate the number of times the clue occurred. Draw a slash mark at an angle in the direction the step was taken.

• Indicate by a check the number of times the subject stops, misses heel-to-toe, steps off line, or raises arms.

• Record the actual number of steps taken.

• If the subject stops walking a slash mark should cross between the feet and be labeled with an “S.”

• The “S” indicates “stopped.”

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Walk and Turn Test Diagram (Cont.)

3-15

M S

• If the subject steps off the line, indicate with a half of slash mark at an angle in the direction the step was taken.

• If the subject misses heel-to-toe, indicate with a slash mark between the feet and label with an “M.

• ”The “M” indicates “missed.”



Walk and Turn Test Diagram Practice

3-16





Hands-On Practice

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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One Leg Stand Test Diagram

3-17

One Leg Stand:


L R

Type of Footwear

C. One Leg Stand

One Leg Stand is the third divided attention test administered during the drug influence evaluation.

• For drug evaluation purposes, One Leg Stand is given twice to the subject.

• First, the subject is required to perform the One Leg Stand while standing on the left foot.

• Note: The One Leg Stand is administered twice to test both the left and right legs to assist the DRE in making comparisons and identify potential medical conditions that may be present.

• Next, they are required to perform the test while standing on the right foot.

• Otherwise, One Leg Stand is used in the same fashion as in Standardized Field Sobriety Testing.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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One Leg Stand TestAdministration

3-18

One Leg Stand:


L R

Type of Footwear

Review of One Leg Stand Administrative Procedures

Two instructors should be used for this demonstration, one as the “subject” and the other as the examiner.

• The test has two stages, the instructions stage and the balance and counting stage.

• During the instructions stage, the subject must stand with the feet together, arms at the side, facing the examiner.

• Demonstrate the stance that the “subject” is required to maintain.

• The subject must be told that they will have to stand on the left foot, and raise the right foot approximately 6 inches off the ground, with the right leg held straight and the raised foot parallel to the ground.

• The examiner must demonstrate the one-leg stance.

• Emphasize that the subject must maintain the foot elevation throughout the test.

• If the subject lowers his/her foot, he/she should be instructed to raise it.

• The subject must be told that they must look at the elevated foot during the test.

• Emphasize that the examiner should not look at his or her own foot while giving the instructions; for safety reasons, the examiner must keep the eyes on the subject at all times.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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One Leg Stand TestAdministration (Cont.)

One Leg Stand:


L R

Type of Footwear

3-19

• The subject must be told that they will have to count out loud in the following manner: “one thousand one, one thousand two, one thousand three” and so on until told to stop.

• After giving the instructions, the examiner should ask the “subject” if they understand.

• Note: If the subject puts the foot down, remind the subject to pick the foot up again and continue counting from the point at which the foot touched.

• After the subject has completed the test on the left foot, they must be told to repeat the test on the right foot.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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One Leg Stand Test DiagramRecording Results

3-20

Recording Results of the One Leg Stand

For drug evaluation purposes, we use the same clues on the One Leg Stand that we use for Standardized Field Sobriety Testing.

The One Leg Stand clues:

• Sways while balancing

• Uses arms to balance

• Hopping

• Puts foot down

Indicate above the feet the number they were counting when they put their foot down.

Check marks should be made to indicate the number of times the subject swayed, used arms for balance, hopped or put their foot down.

The subject’s actual count during the 30 seconds should be documented in the top area of the box above the foot on which the subject was standing.



One Leg Stand Hands-On Practice

One Leg Stand:


L R

Type of Footwear

3-21

Hands-On Practice

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Finger to Nose Test Diagram

3-22

Right Left

Draw lines to spots touched

2

4

5

1

3

6

D. Finger to Nose

The Finger to Nose is the final divided attention test used in the drug influence evaluation.

Finger to Nose differs from the other three tests in that the examiner must continue to give instructions to the subject throughout the test.



Finger to Nose TestAdministrative Procedures

3-23

Right Left


2

4

5

1

3

6

Administrative Procedures for Finger to Nose

• The subject must be told that he/she will be given a series of commands, i.e., “left, right, etc.” to indicate which fingertip is to be brought to the tip of the nose.

• The subject must be told to stand with feet together, arms down at the sides, facing the examiner.

• The examiner should demonstrate the stance.

• The subject must be told to close his/her hands, rotate the palms forward and then to extend the index fingers from the closed hands.

• The examiner must tell subject that they will be asked to touch the tip of the index finger to the tip of the nose.

• The examiner must demonstrate to the subject how they are expected to touch the fingertip to the nose. (Without actually touching the nose.)

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Finger to Nose TestAdministrative Procedures (Cont.)

3-24

Right Left


2

4

5

1

3

6

• Demonstrate: “When I say ‘left,’ touch the tip of your left index finger to the tip of your nose.

• The examiner must tell the subject that they are expected to return the arm to the side immediately after touching the fingertip to the nose.

• Demonstrate the movement of the fingertip to the nose by standing at an angle to the “subject” so that he/she can see the proper method for touching the nose.

• The subject must be told to tilt the head back slightly and to close the eyes, and keep them closed until the examiner says to open them.

• Note: The subject’s head should be tilted back in the same fashion as in the Modified Romberg Balance test.

• The examiner should demonstrate the stance with head tilted back, arms at the sides with index fingers extended. Remind the participants that they should not close their eyes during the instructions for safety reasons.



Finger to Nose TestAdministrative Procedures (Cont.)

3-25

Right Left


2

4

5

1

3

6

Instructor-Led Demonstrations

• Instructor-to-instructor demonstration.

• Instructor-to-participant demonstration.

Participant-Led Demonstrations

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Finger to Nose TestRecording Results

3-26

Recording Results of the Finger to Nose Test

• The results of Finger to Nose test are recorded by drawing a “map” showing where the fingertips landed on each attempt.

• A line should be drawn to the appropriate triangle to indicate where the subject touched their nose.

• Suggestion: If the DRE draws the line from the place where the subject touches to the appropriate triangle, it enables them to draw a straighter line.

Hands-on Practice



QUESTIONS?

3-27

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 1 of 28

Participant Manual DRE Pre School - Session 4 – The Eye Examinations

Session 4 – Eye Examinations


Session 4

The Eye Examinations

90 Minutes



• Administer tests of Horizontal Gaze Nystagmus, Vertical Gaze Nystagmus and Lack of Convergence

• Estimate pupil size

• Relate the expected results of the eye examinations to the seven categories of drugs

Learning Objectives

4-2


• Administer tests of Horizontal Gaze Nystagmus, Vertical Gaze Nystagmus and Lack of Convergence.

• Estimate pupil size.

• Relate the expected results of the eye examinations to the seven categories of drugs.


A. Purposes of the Eye Examinations Instructor-Led Presentations B. Procedures and Clues Instructor-Led Demonstrations C. Demonstrations Hands-on Practice

D. Relationship of Drug Categories to

the Eye Examinations

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Eye Examination Purpose

4-3

A. Purposes of the Eye Examinations

The principal purpose of all of the eye examinations is to obtain articulable facts indicating the presence or absence of specific categories of drugs.

• Certain drug categories usually cause the eyes to react in specific ways.

• Other drug categories usually do not cause those reactions.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Eye Examination-HGN

4-4

Horizontal Gaze Nystagmus (HGN)

The tests of Horizontal Gaze Nystagmus (HGN) and Vertical Gaze Nystagmus (VGN) provide important indicators of the drug categories that may or may not be present.

• Prior to the administration of the HGN, the subject’s eyes should be checked for equal pupil size, resting nystagmus and equal tracking.

• The check for equal pupil size is simply done by visibly checking to see if both pupils are equal in size. If they are not, this may be an indicator of a head injury or other medical conditions.

• The check for equal tracking is done by moving the stimulus smoothly across the subject’s entire field of vision checking to see if the eyes track together or if one lags behind.

• If the subject’s pupils are noticeably unequal in size or if resting nystagmus is present or if the eyes do not track together, there may be a chance of a medical condition or pathological disorder.

• This part of the examination may require more than one check to ensure that a medical condition or pathological disorder does not exist.

• If HGN is observed, it is likely that the subject may have taken a CNS Depressant, Dissociative Anesthetic, an Inhalant, or a combination of those.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Eye Examination-VGN

4-5

Vertical Gaze Nystagmus (VGN)

• If VGN if observed, the implication may be that the subject took Dissociative Anesthetics, or fairly large doses of depressants or inhalants (for that individual).

• Point out that it is very unlikely that a subject would exhibit Vertical Gaze Nystagmus without also exhibiting HGN.

• By comparing the subject’s blood alcohol concentration with the angle of onset of HGN, it may be possible to determine that alcohol is or is not the sole cause of the observed nystagmus.



Eye Examination - Angle of Onset

4-6

BAC = 50 - Angle of Onset

Angle of Onset

The consistency of onset angle and BAC can be compared using the following formula:

• Explanation: BAC = 100 x blood alcohol (e.g., if blood alcohol is 0.10, BAC = 10).

• Example: If onset angle is 35 degrees, then BAC = 50 - 35 = 15.

• The corresponding blood alcohol concentration would be approximately 0.15.

• Keep in mind that this formula is only a statistical approximation. It is not an exact relationship for all subjects at all times.

• The only purpose of comparing BAC and the angle of onset is to obtain a gross indication of the possible presence of another Depressant, Inhalant, or Dissociative Anesthetic.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Eye Examination - Angle of Onset (Cont.)

4-7

Angle of Onset = 35 degreesBAC = 50 – Angle of Onset

= 50 – 35= 15

• A DRE is expected to be able to estimate the angle of onset of nystagmus to the nearest 5 degree increment, over the range from 30 to 45 degrees.

• If the subject’s eyes begin to jerk before they have moved to the 30 degree mark, you will not attempt to estimate the angle precisely, but will record that they exhibit “immediate onset.”

• From 30 degrees on out, you will record a numeric estimate of onset. Session 4 – Eye Examinations


Eye Examination –Lack of Convergence

4-8

Lack of Convergence (LOC)

The check for Lack of Convergence (LOC) can provide another clue as to the possible presence of Depressants, Inhalants, or Dissociative Anesthetics.

Lack of Convergence is also an indicator of the possible presence of Cannabis.

The checks of pupil size, equal tracking and reaction to light provide useful indicators of the possible presence of many drug categories. • CNS Depressants, CNS Stimulants and Inhalants will usually cause the pupils to

react slowly to light.

• CNS Stimulants, Hallucinogens and Cannabis usually will cause the pupils to dilate.

• Narcotic Analgesics will usually cause the pupils to constrict, with little or no reaction to light.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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• Lack of Smooth Pursuit

• Distinct and Sustained Nystagmus at Maximum Deviation

• Angle of Onset

Three Clues of Horizontal Gaze Nystagmus

4-9

B. Procedures and Clues


Prior to the administration of the HGN test, the eyes are checked separately for equal pupil size, resting nystagmus and equal tracking.

• Note: As pointed out earlier, if the eyes do not track together, or if the pupils are noticeably unequal in size, the chance of a medical disorder or injuries causing the nystagmus may be present. Resting nystagmus may also be observed at this time.

Horizontal Gaze Nystagmus test consists of three separate checks, administered independently to each eye.

Lack of Smooth Pursuit

The first check is for “lack of smooth pursuit.”

• Position the stimulus approximately 12 to 15 inches from of the subject’s nose.

• Hold the tip of the stimulus slightly above the subject’s eye level.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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• Angle of Onset

Three Clues of Horizontal Gaze Nystagmus (Cont.)

4-10

Click on Picture for Video Example of Lack of Smooth Pursuit

• Instruct the subject to hold their head still and follow the stimulus with the eyes only.

• Move the stimulus smoothly, all the way to the subject’s left, then all the way to the right, then back again all the way to the left, then once again all the way back to the right.

• While the eye is moving, examine it for evidence of a lack of smooth pursuit.

Use these or similar analogies:

• A smoothly pursuing eye will move without friction, much the way that a windshield wiper glides across the windshield when it is raining steadily. An eye showing lack of smooth pursuit will move in a fashion similar to a wiper moving across a dry windshield.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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• Angle of Onset


4-11

Participant Practice Distinct and Sustained Nystagmus at Maximum Deviation

The second check is for “distinct and sustained nystagmus at maximum deviation.”

• Again position the stimulus as before.

• Move the stimulus all the way to the subject’s left side and hold it there so that the subject’s eye is turned as far to the side as possible.

• Hold the eye at that position for a minimum of 4 seconds, to check carefully for any jerking that may be present.

• Then, move the stimulus all the way to the subject’s right side, and hold it there for a minimum of 4 seconds.





• Angle of Onset


4-12

Click on Picture for Video Example of Maximum Deviation

A slightly or barely visible tremor is not sufficient to consider this cue present.

A definite, strong jerking must be seen.

Participants’ initial practice of the check for distinct and sustained nystagmus at maximum deviation.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Horizontal Gaze Nystagmus

4-13

Angle of Onset

The final check is for the “angle of onset.” The formula is BAC = 50 – Angle of Onset.

• Position the stimulus as before.

• Slowly move the stimulus to the subject’s left side, carefully watching the eye for the first sign of jerking.

• When you think that you see the eye jerk, stop moving the stimulus and hold it still.

• Verify that the eye is, in fact, jerking.

• Once you have established that you have located the point of onset, estimate the angle.

• Repeat this procedure on the subject’s right eye.





• Angle of Onset

4-14


Click on Picture for Video Example of Angle of Onset

Participant Practice

• Participants’ initial practice of angle of onset estimation.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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• Standardization

• Medical Complications


4-15 Session 4 – Eye Examinations


Vertical Gaze Nystagmus

4-16

Click on Picture for Video Example of Vertical Gaze Nystagmus

Vertical Gaze Nystagmus

The Vertical Gaze Nystagmus test is a very simple test.

• Position the stimulus horizontally, approximately 12 to 15 inches in front of the subject’s nose.

• Point out to the subject that he or she will have to keep their head steady and try to keep their eyes focused on the stimulus as it moves upward.

• Raise the stimulus until the subject’s eyes are elevated as far as possible.

• Watch closely for evidence of jerking.


Participants’ initial practice of the Vertical Gaze Nystagmus test.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 11 of 28



Lack of Convergence (LOC)

4-17

Lack of Convergence

The test for Lack of Convergence (LOC) determines whether the subject is able to cross his or her eyes.

• Position the stimulus approximately 12 to 15 inches in front of the subject’s nose in the same position we use for the HGN test.

• Inform the subject that you are going to move the stimulus around in a circle in front of his or her face and to follow the stimulus with his or her eyes only.

• Inform the subject that you will move the tip of the stimulus in toward the bridge of his or her nose.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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• Begin by moving the stimulus in a circle in front of the subject's face

• Observe the eyes to verify that the subject is tracking the stimulus

• Slowly move the stimulus in toward the bridge of the nose

LOC Testing Procedure (Cont.)

Examiner Subject

4-19

• Start to move the object slowly in a circle.

• Verify the subject is tracking the stimulus.

• Move the stimulus within approximately two inches of the bridge of the nose. Carefully observe the subject’s eyes to determine whether both eyes converge on the stimulus.



Normal convergence is a distance approximately two inches (2”) from the

bridge of the nose

Examiner Subject

2”

4-20

• If the eyes converge (cross) when the stimulus is approximately two inches from the bridge of the nose, the Lack of Convergence is “not present“

• Lack of convergence is present if the subject’s eyes do not come together and cross as they track and stay aligned on the stimulus

• In a normal non-impaired subject, the eyes should come together (converge) and remain converged for one second.

• If the eyes do not converge or remain converged on the stimulus for one second, then Lack of Convergence is present.


Participants’ initial practice of the test for Lack of Convergence.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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The following drug categories usually will induce Lack of Convergence:

• CNS Depressants

• Inhalants

• Dissociative Anesthetics

• Cannabis

Drug Categories That Induce LOC

4-21

Drug categories which usually cause lack of convergence include:

• CNS Depressants

• Inhalants

• Dissociative Anesthetics

• Cannabis Session 4 – Eye Examinations


Estimating Pupil Size

4-22

Estimation of Pupil Size

We use a device called a pupillometer to estimate the size of the subject’s pupil.

The DRE pupillometer has a series of circles or semi-circles, with diameters usually ranging from 1.0 mm to 10.0 mm, in half millimeter increments.

The pupillometer is held alongside the subject’s eye, and moved up and down until the circle or semi-circle closest in size to the pupil is located.

The pupil size estimations are recorded as the numeric value that corresponds to the diameter of the circle or semi-circle closest in size to the subject’s pupil in each lighting condition.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Estimating Pupil Size (Cont.)

4-23

Participants’ Initial Practice of Pupil Size Estimation Session 4 – Eye Examinations


Estimating Pupil Size (Cont.)

4-24

DRE Average range of pupil size in room light is 2.5 to 5.0 mm

8.5 or larger __________

8.0__________

7.5__________

7.0__________

6.5__________

6.0__________

5.5__________

5.0__________

4.5__________

4.0__________

3.5__________

3.0__________

2.5 or smaller_________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Three Testing Conditions for Pupil Size Estimations

Near Total Darkness

Room Light

Direct Light

4-25

Three Lighting Conditions

We estimate pupil size under three (3) different lighting conditions:

• Room Light

• Near Total Darkness

• Direct Light Session 4 – Eye Examinations


We ALSO know that …. There are three conditions for other physiological indicators

These Three Testing Conditions Create Different Demands on the Autonomic Nervous System Including the Pupil

4-26

• Different testing conditions create different demands on the autonomic nervous system, including the pupil.

• Examining the pupils in three different lighting conditions is similar to examining other clinical indicators, i.e., pulse or blood pressure in different conditions.

In the DEC program and DRE training we use the terms “Normal”, “Average”, “Average Ranges” or “DRE Average Range”.

“Normal” means a range of values that represents the “middle” or “typical” value that the majority of healthy, non-impaired people would be expected to exhibit or have in a specific test.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Estimation of Pupil Size

4-27

• Pupils are examined in Room Light prior to darkening the room

• The final two pupil size estimations are made with the use of a penlight in a near totally darkened room

• Prior to estimating the pupil sizes, we darken the room and wait 90 seconds to allow the subject’s eye to adapt to the dark

Estimation of Pupil Size under Room Light

• Pupils are examined in Room Light prior to darkening the room. Estimation of Pupil Size under Near Total Darkness and Direct Light

The final two pupil size estimations are made with the use of a penlight in a near totally darkened room.

• Prior to estimating the pupil sizes, we darken the room and wait 90 seconds to allow the subject’s eyes and our own to adapt to the dark.

• For the estimation under near total darkness, completely cover the tip of the penlight with your finger or thumb, so that only a reddish glow and no white light emerges.

• Bring the glowing red tip up toward the subject’s left eye until you can distinguish the pupil from the colored portion of the eye (iris).

• Position the pupillometer alongside the pupil (left eye first) and locate the circle or semi-circle that is closest in size to the pupil.

• Repeat the procedure for the subject’s right eye.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Estimation of Pupil Size Darkroom Demonstrations

4-28

• For the estimation under direct light, bring the uncovered light from the side of the subject’s face directly into his or her left eye and hold it there for approximately 15 seconds

• For the estimation under direct light, bring the uncovered light from the side of the subject’s face directly into his or her left eye and hold it there for approximately 15 seconds.

• Bring the pupillometer up alongside the left eye, and find the circle or semi-circle that is closest in size to the pupil.

• Repeat the procedure for the right eye. Average Sizes for the Pupil

Since we estimate pupil size under three different lighting conditions (Room Light, Near Total Darkness, and Direct Light) the range of pupil sizes will vary.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Mean or Average:

• The average value of a given set of findings

Average Range: (1.5 Standard Deviation)

• The range of data in which 88% or greater of the findings are included

Recent Research for DRE Average Values

4-29

Basic Concepts Relative to Interpreting Pupil Sizes

It is important to understand a few basic concepts relative to interpreting pupil sizes. Understanding these concepts will allow DRE’s to better understand the relationship of pupil size to impairment.

Mean values and average ranges: scientifically validated studies were conducted to determine normative values for pupil size in non-impaired persons. These studies show what one would expect a person to exhibit when their pupil sizes are checked under different lighting conditions. Sometimes average means “in the middle” or sum of all numbers divided by the number in a particular group. What we use for interpretation purposes are “average ranges” of pupil sizes.

• As a DRE, you will be making your decision of impairment based on clinical, psychophysical, and behavioral indicators. This includes using pupil sizes as one of the factors in determining that impairment.

• With many people, even under very bright light, the pupils won’t constrict much below a diameter of 2.0 mm, and even under near total dark conditions, the pupils usually only dilate to a diameter of not more than 8.5 mm.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Updated Values – Where did they come from specifically related to

DRE?

4-30

• Studies have indicated there are significant differences between the average pupil size in these three conditions. (Source: See Below)

• Consequently, the use of three distinct pupil sizes range for each of the different testing conditions may be more useful to determine impairment versus non-impairment.

Source: “An Evaluation of Pupil Size Standards Used By Police Officers for Detecting Drug Impairment” JAOA, March 2004, Richman, McAndrew, Decker & Mullaney.



10.0 mm 0.00%

9.5 mm 0.00%

9.0 mm 0.00 %

8.5 mm 0.00%

8.0 mm 0.00%

7.5 mm 0.45%

7.0 mm 1.12%

6.5 mm 1.79%

6.0 mm 0.89%

5.5 mm 3.35%

5.0 mm 4.24%

4.5 mm 13.17%

4.0 mm 23.66%

3.5 mm 24.11%

3.0 mm 18.08%

2.5 mm 5.36%

2.0 mm 0.89%

1.5 mm 0.00%

1.0 mm 0.00%

Room Light is approximately 4.0 mm. with an average range of pupil sizes ranging from 2.5 to 5.0 mm.

88% fall within the range of 2.5 to 5.0 mm.

In fact, the percentage that falls within 3.5 to 4.5 mm is more than

half (61%) of the people.

4-31

Room Light

• Room Light is approximately 4.0 mm with an average range of sizes ranging from 2.5 to 5.0 mm.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 20 of 28



Near Total Darkness

10 mm 0.00%

9.5 mm 0.22%

9 mm 4.80%

8.5 mm 6.92%

8 mm 8.93%

7.5 mm 11.00%

7 mm 14.07%

6.5 mm 15.17%

6 mm 13.02%

5.5 mm 10.00%

5 mm 8.93%

4.5 mm 4.47%

4 mm 1.79%

3.5 mm 1.00%

3 mm 0.00%

Near Total Darkness is approximately 6.5 mm with an average range of pupil sizes ranging from 5.0 to 8.5 mm.

About 88% fall within the range of 5.0 to 8.5 mm.

In fact, the percentage that falls within 6.0 to 7.5 mm is over 53

percent of the people.

4-32

Near Total Darkness

• Near Total Darkness is approximately 6.5 mm with an average range of pupil sizes ranging from 5.0 to 8.5 mm.



10.0 mm 0.00%

9.5 mm 0.00%

9.0 mm 0.00 %

8.5 mm 0.00%

8.0 mm 0.00%

7.5 mm 0.44%

7.0 mm 1.12%

6.5 mm 0.89%

6.0 mm 1.79%

5.5 mm 3.35%

5.0 mm 4.24%

4.5 mm 13.17%

4.0 mm 23.66%

3.5 mm 24.11%

3.0 mm 21.08%

2.5 mm 5.36%

2.0 mm 0.89%

1.5 mm 0.00%

1.0 mm 0.00%

Direct Light is approximately 3.0 mm with an average range of pupil sizes ranging from 2.0 to 4.5 mm

88% fall within the range of 2.0 to 4.5 mm.

In fact, the percentage that falls within 3.0 to 4.0 mm is almost 69

percent of the people.

4-33

Direct Light

• Direct Light is approximately 3.0 mm with an average range of pupil sizes ranging from 2.0 to 4.5 mm

Many drugs, however, will affect the dilation or constriction of the pupils and many cause the pupil size to go outside these ranges

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Pupil Reaction Time • Check of the pupil’s reaction to light takes

place at the same time as the test of pupil size under direct light

• Observe the subject’s pupil size as the penlight is aimed directly at the eye

• As you bring the beam of light directly into the subject’s eye, note how the pupil reacts

• Under ordinary conditions, the pupil should react very quickly, and constrict noticeably when the light strikes the eye

The check of the pupil’s reaction to light takes place at the same time as the test of pupil size under direct light.

• Observe the subject’s pupil size as the penlight is aimed directly at the subject’s eye. • As you bring the beam of light directly into the subject’s eye, note how the pupil

reacts. • Under ordinary conditions, the pupil should react very quickly, and constrict noticeably

when the light beam strikes the eye.

• Under the influence of certain categories of drugs, the pupil’s reaction may be very sluggish, or there may be no constriction at all.



Pupil Reaction Time



Participants’ initial practice in measuring the pupil’s reaction to light.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Equal Tracking;

Equal Pupil Size;

HGN


C. Demonstrations Estimation of the Angle of Onset



VGN and LOC


Demonstration of Vertical Gaze Nystagmus and Lack of Convergence Session 4 – Eye Examinations


Pupil Size; Reaction to Light


Demonstration of Pupil Size Estimation and Test for Reaction to Light

• Pupil size estimation under room light.

• Darkroom estimations of pupil size.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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• Room Light: 4.0 mm with average range of 2.5 – 5.0 mm

• Near Total Darkness: 6.5 mmwith average range of 5.0 – 8.5 mm

• Direct Light: 3.0 mm with average range of 2.0 – 4.5 mm

Pupil Size Ranges Recap

4-39

To review, the DRE pupil size ranges for non-impaired people are:

• Room Light: 4.0 mm with an average range of 2.5 – 5.0 mm.

• Near Total Darkness: 6.5 mm with an average range of 5.0 – 8.5 mm.

• Direct Light: 3.0 mm with an average range of 2.0 – 4.5 mm. Session 4 – Eye Examinations


Relationship of Drug Categories to the Eye Examinations

4-40

CNSDepressants

CNSStimulants

Halluci-nogens

DissociativeAnesthetics

NarcoticAnalgesics

Inhalants Cannabis

HGN Present Present PresentNone None None None

D. Relationship of Drug Categories to the Eye Examinations

Three of the seven drug categories normally will cause Horizontal Gaze Nystagmus. • CNS Depressants, Inhalants and Dissociative Anesthetics normally will cause HGN. • The other four categories normally will not cause HGN.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Relationship of Drug Categories to the Eye Examinations (Cont.)

CNSDepressants

CNSStimulants

Halluci-nogens


NarcoticAnalgesics

Inhalants Cannabis

HGN

VGN

Lack of Convergence

Present Present PresentNone None None None

Present Present Present

FOOTNOTE: These indicators are those most consistent with the category, keep in mind that there may be variations due to individual reaction, dose taken and drug interactions.

None None None None


• Any drug that will cause HGN also will cause Vertical Gaze Nystagmus, if a high enough dose of the drug is taken.

• Depressants, Inhalants and Dissociative Anesthetics can all cause Vertical Gaze Nystagmus at higher doses for that individual.

• But if a drug will not cause HGN, then it will not cause Vertical Gaze Nystagmus.

All drugs that cause nystagmus also will cause the eyes to be unable to converge.

• Therefore, Depressants, Inhalants and Dissociative Anesthetics, including PCP and its analogs, usually will cause Lack of Convergence.

• Interestingly, there is one category of drug that does not cause nystagmus but that does usually cause Lack of Convergence.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Present

CNSDepressants

CNSStimulants

Halluci-nogens


NarcoticAnalgesics

Inhalants Cannabis

HGN

VGN

Lack of Convergence

Pupil Size

Present

Present

Present

Present

Present

None None

None

None

Present

None

None

None

Dilated Dilated Dilated (6)

(6) Pupil size possibly normal.

Constricted Normal Normal (4)

(4) Normal, but may be dilated.


Present Present

Present

None None None

None

• Cannabis usually does cause Lack of Convergence, even though it does not cause nystagmus.

• The other three categories do not cause a Lack of Convergence.

An interesting and important fact is that the drugs that cause nystagmus usually don’t affect pupil size, and the drugs that don’t cause nystagmus usually do affect pupil size.

• CNS Stimulants and Hallucinogens usually cause the pupils to become larger or “dilated.”

• Cannabis may cause the pupils to dilate.

• Narcotic Analgesics usually cause the pupils to become smaller or “constricted.”

• Dissociative Anesthetics and most Inhalants tend to leave pupil size in the average ranges.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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CNSDepressants

CNSStimulants

Halluci-nogens


NarcoticAnalgesics

Inhalants Cannabis

HGN

VGN

Lack of Convergence

Reaction to Light

Pupil Size

Present

Present

Present

Present Present

Present

Present

None

None

None

None

None

None

None

Dilated Dilated Dilated (6)

(6) Pupil size possibly normal. (4) Normal, but may be dilated.

Normal Constricted Normal (4) Normal (1)

(1) Soma, Quaaludes and possibly some anti-depressants usually dilate pupils.

Slow Slow Normal Normal Normal



None

None None None

CNS Depressants also usually leave the pupils near the average range.

• However, there are some exceptions, i.e., depressant drugs that usually dilate the pupils.

Soma, Quaaludes and some anti-depressants usually dilate pupils.

Generally, the pupillary reaction to light is either slowed by the effect of the drug or the pupil reacts normally. The most significant exception is the effect caused by Narcotic Analgesics. Though there is always some reaction to light, in subjects, the constricted pupil caused by narcotics makes it difficult to perceive a change in the pupil size.

• CNS Depressants and CNS Stimulants usually cause a slowed reaction to light.

• With Hallucinogens, Dissociative Anesthetics and Cannabis the pupillary reaction to light is usually normal.




CNSDepressants

CNSStimulants

Halluci-nogens


NarcoticAnalgesics

Inhalants Cannabis

HGN

VGN

Lack of Convergence

Reaction to Light

Pupil Size

(1) Soma, Quaaludes and possibly some anti-depressants usually dilate pupils.

(4) Normal, but may be dilated. (6) Pupil size possibly normal.

Present Present

Present Present

Present

None

None

None

None

None

None

Dilated Dilated Normal Constricted Normal (4) Normal (1)

Slow Slow Normal

Present

Present

Dilated (6)

Normal

None

Normal

(3) Certain psychedelic amphetamines may cause slowing.


(3) Little to None Visible

Slow

None

None

None

Present Present PresentNone

Due to the constricted nature of the pupils when under the influence of Narcotic Analgesics, it is difficult to perceive a reaction to light. As a result, we list reaction to light for Narcotic Analgesics as “little or none visible.”

Inhalants will usually slow pupillary reaction.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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QUESTIONS?

4-45

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Review Questions

1-46

REVIEW QUESTIONS

1. Name the three clues of impairment associated with Horizontal Gaze Nystagmus.

2. Complete this formula BAC = 50 - ??? :

3. Which categories of drugs will not cause Vertical Gaze Nystagmus?

4. Which categories of drugs usually will cause Lack of Convergence?

5. Name the three lighting conditions under which a DRE makes pupil size estimations.

6. What is the average range of pupil size for room light?

7. Which categories of drugs will usually slow down the reaction of the pupils to light?

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 1 of 3

Participant Manual DRE Pre School - Session 5 – Alcohol Workshop

Session 5 – Alcohol Workshop

Preliminary Training for Drug Evaluation and Classification ProgramProgram

Session 5

Alcohol Workshop

120 Minutes



• Administer the psychophysical tests and the eye examinations to persons who have consumed varying amounts of alcohol

• Document the results of these tests and examinations

• Accurately assess the extent of a person’s alcohol impairment based on the tests and examinations

Learning Objectives

5-2


• Administer the psychophysical tests and the eye examinations to persons who have consumed varying amounts of alcohol.

• Document the results of these tests and examinations.

• Accurately assess the extent of a person’s alcohol impairment based on the tests and examinations.


A. Assignments and Procedures Hands-on Practice B. Testing Participant-Led Presentations C. Feedback and Discussion D. Alcohol Workshop Checklist

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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• One member will be an examiner and will complete all portions of the exam

• One member will be the recorder and document the findings of the examination on the evaluation form

• All others in the group will observe/coach

• Each team member will conduct at least one complete examination

Team Assignments

5-3

A. Assignments and Procedures



• Horizontal Gaze Nystagmus (record onset angle in each eye)

• Vertical Gaze Nystagmus• Lack of Convergence• Modified Romberg Balance• Walk and Turn• One Leg Stand (on left foot)• One Leg Stand (on right foot)• Finger to Nose

Testing Procedures

5-4

Explanation of Testing Procedures

Each team will conduct the following sequence of tests and examinations on each volunteer:

• HGN (record angle of onset in each eye).

• Vertical Gaze Nystagmus.

• Lack of Convergence.

• Modified Romberg Balance.

• Walk and Turn.

• One Leg Stand (standing on left leg).

• One Leg Stand (standing on right leg).

• Finger to Nose

Upon completing the test and examinations, the team members will record their best estimate as to the volunteer’s BAC.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 3 of 3



Testing

5-5

B. Testing

C. Feedback and Discussion

D. Alcohol Workshop Checklist



QUESTIONS?6

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 1 of 20

Participant Manual DRE Pre School - Session 6 – Examinations of Vital Signs

Session 6 – Examinations of Vital Signs


• List the vital signs that are utilized in the DRE examinations

• Define basic terms relevant to pulse rate and blood pressure measurements

• Measure pulse rate• Measure blood pressure• Relate the expected results of vital signs

examinations to the various categories of drugs

Learning Objectives

6-2


• List the vital signs that are utilized in the DRE examinations.

• Define basic terms relevant to pulse rate and blood pressure measurements.

• Measure pulse rate.

• Measure blood pressure.

• Relate the expected results of vital signs examinations to the various categories of drugs.


A. Purposes of the Examinations Instructor-Led Presentations B. Procedures and Cues Participant-Led Demonstrations C. Demonstrations Hands-on Practice D. DRE Ranges of Vital Signs E. Relationship of Drug Categories

to the Vital Signs Examinations F. Practice



Session 6

Examinations of Vital Signs

180 Minutes



Session 6

Examinations of Vital Signs

180 Minutes Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 2 of 20



• Pulse rate• Blood pressure• Temperature

Different types of drugs affect these vital signs in different ways

Vital Signs

6-3

A. Purposes of the Examinations

The vital signs that are relevant to the drug influence evaluation process include:

• Pulse rate

• Blood pressure

• Temperature

Different types of drugs affect these vital signs in different ways.

Certain drugs tend to “speed up” the body and elevate these vital signs.

Clarification:

• Pulse may quicken

• Blood pressure may rise

• Temperature may rise

Other drugs tend to “slow down” the body and lower these vital signs.

Clarification:

• Pulse may slow

• Blood pressure may drop

• Temperature may fall

Systematic examination of the vital signs gives us much useful information concerning the possible presence or absence of various categories of drugs.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 3 of 20



• PulseThe expansion and contraction of an artery generated by the pumping action of the heart

• Pulse RateThe number of pulsations in an artery per minute

• ArteryA strong, elastic blood vessel that carries blood from the heart to the body tissues

• VeinA blood vessel that carries blood back to the heart from the body tissues

Definitions Concerning “Pulse”

6-4

B. Procedures and Cues

Measurement of Pulse Rate

• Pulse is the expansion and contraction of an artery generated by the pumping action of the heart.

• Pulse rate is the number of pulsations in an artery per minute.

• An artery is a strong, elastic blood vessel that carries blood away from the heart.

• A vein is a blood vessel that carries blood back to the heart.

• When the heart contracts, it squeezes blood out of its chambers into the arteries.

• The surging blood causes the arteries to expand.

By placing your fingers on the skin next to an artery and pressing down, you can feel the artery expand as the blood surges through.

By keeping your fingers on the artery and counting the number of pulses that occur in one minute, you will measure the pulse rate.

Pulse is easy to measure, once you locate an artery close to the surface of the skin.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Radial Artery

Radial ArteryPulse Point

6-5

Radial Artery

One convenient pulse point involves the radial artery.

• The radial artery can be located in or near the natural crease of the wrist, on the side of the wrist next to the thumb.

• Point to the radial artery pulse point on your own wrist. • Hold your left hand out, with the palm down. • Place the tips of your right hand’s index finger and middle finger into the crease of

your left wrist, and exert a slight pressure. • Allow your left hand to curl downward. • You should be able to feel the pulse in your radial artery.



Brachial Artery

Brachial ArteryPulse Point

6-6

Brachial Artery

Another pulse point involves the brachial artery.

• The brachial artery can be located in the crook of the arm, halfway between the center of the arm and the side of the arm closest to the body.

• Hold your left hand out, with the palm up. • Place the tips of your right hand’s index and middle fingers into the crook of your left

arm, close to the body, and exert a slight pressure. • You should be able to feel the pulse in your brachial artery.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Carotid Artery

Carotid ArteryPulse Point

6-7

Carotid Artery

Another pulse point involves the carotid artery.

• The carotid artery can be located in the neck, on either side of the middle of the throat (“Adam’s Apple”).

Place the tips of your right hand’s index and middle fingers alongside the right side of your “Adam’s Apple.”

• You should be able to feel the pulse in your carotid artery. Session 6 – Examinations of Vital Signs


Basic Do’s and Don’ts of Measuring Pulse

6-8

• Don’t use your thumb to apply pressure

• If you use the carotid artery pulse point, don’t apply pressure to both sides of the middle of the throat

• When measuring the pulse rate, use 30 seconds as the standard time interval

• Pulse rate is always expressed as “beats per minute”

• The pulse reading should not be an odd number

Basic Do’s and Don’ts of Measuring Pulse

• Don’t use your thumb to apply pressure while measuring a subject’s pulse.

• If you use the carotid artery pulse point, don’t apply pressure to both sides of the middle of the throat: this can cut off the supply of blood to the brain.

• When measuring the pulse rate, use 30 seconds as the standard time interval.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Pulse Hands On Practice

• Work in pairs, taking turns measuring each other’s pulse

• Record partner’s pulse rate

6-9

Participants’ Initial Practice at Measuring Pulse Rate

Monitor, coach and critique the participants’ practice. Allow the practice to continue for only about 5 minutes.

50 or less____ 76-78____

52-54____ 80-82____

56-58____ 84-86____

60-62____ 88-90____

64-66____ 92-94____

68-70____ 96-98____

72-74____ 100+____

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Definitions Concerning “Blood Pressure”

• Blood PressureThe force that the circulating blood exerts on the walls of the arteries

• Systolic PressureThe maximum blood pressure, reached as the heart contracts

• Diastolic PressureThe minimum pressure, reached when the heart is fully expanded

6-10

Measurement of Blood Pressure

Blood pressure is the force that the circulating blood exerts on the walls of the arteries.

• Blood pressure changes constantly as the heart contracts and relaxes.

• Blood pressure reaches its maximum as the heart contracts and sends the blood surging through the arteries. This is called the systolic pressure.

• Blood pressure reaches it minimum when the heart is fully expanded. This is called the diastolic pressure.

• It is always necessary to measure and record both the systolic and diastolic blood pressure.



Sphygmomanometer

6-11

The device used for measuring blood pressure is called a sphygmomanometer.

The sphygmomanometer has a special cuff that can be wrapped around the subject’s arm and inflated with air pressure.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Sphygmomanometer Demonstration

6-12

• As the pressure in the cuff increases, the cuff squeezes tightly on the arm.

• When the pressure gets high enough, it will squeeze the artery completely shut.

• Blood will cease flowing through the brachial artery. Since the brachial artery “feeds” the radial artery, blood will also cease flowing through the radial artery.

If we slowly release the air in the cuff, the pressure on the arm and on the artery will start to drop.

• Eventually, the pressure will drop enough so that blood will once again start to flow through the artery.

• Blood will start flowing in the artery once the pressure inside the artery equals the pressure outside the artery.



Sphygmomanometer Demonstration (Cont.)

6-13

• The two pressures will become equal when the air pressure in the cuff drops down to the systolic pressure.

• Point out that the blood would spurt through the artery each time the heart contracted, but would cease flowing when the heart expanded.

• When that happens, blood will spurt through the artery each time the heart contracts.

• Once the air pressure in the cuff drops down to the diastolic level, the blood will flow continuously through the artery.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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The Basics of Blood Pressure Measurement

• Apply enough air pressure to cut off the flow of blood through the artery

• Slowly release the air, about 2 mmHg per second, until the blood just begins to spurt through the artery: THAT WILL BE THE SYSTOLIC PRESSURE

• Continue to release the air until the blood flows continuously: THAT WILL BE THE DIASTOLIC PRESSURE

6-14

Overview of Procedures for Measuring Blood Pressure

• Apply enough air pressure to the cuff to cut off the flow of blood through the artery (approximately 180 mmHg).

• Slowly release the air pressure until the blood just begins to spurt through the artery: that level will be the systolic pressure.

• Slowly release the pressure in the cuff.

• Emphasize that the pressure should drop at approximately 2 mmHg per second (5 sec for each 10 mm drop).

• Continue to release the air pressure until the blood flows continuously through the artery: that level will be the diastolic pressure.

We can listen to the spurting blood, using a stethoscope.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Taking Blood Pressure with a Stethoscope

6-15

• Apply the stethoscope to the skin directly above the artery.

• Apply pressure to the cuff, enough to cut off the flow of blood.

• Inflate the cuff on the participant-volunteer’s arm.

• When no blood is flowing through the artery, we hear nothing through the stethoscope.

• Slowly release the air from the cuff, letting the pressure start to drop.

• Release the air in the cuff.

• When we drop to the systolic pressure, we start to hear a spurting sound.

• As we continue to allow the air pressure to drop, the surges of blood become steadily longer.

• When we drop to the diastolic pressure, the blood slows steadily and all sounds cease.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Korotkoff Sounds

Phase 1 begins Systolic Clear, tapping sounds

Phase 2 begins Sounds change to murmur, take on a “swishing” quality

Phase 3 begins Sounds develop a loud, knocking quality

Phase 4 begins SoundsBecome muffled, faint “swishing” quality

Phase 5 begins DiastolicThe sounds cease

6-16

Click to Hear Audio Sample of Korotkoff

Sounds

Korotkoff Sounds

The sounds that we listen to are called Korotkoff Sounds. Named after Dr. Nikolai Korotkoff, a Russian physician who introduced the method of determining blood pressure in 1905.

Phase 1: the first appearance of clear, tapping sounds that gradually increase in intensity.

Phase 2: the sounds change to a murmur and take on a swishing quality.

Phase 3: the sounds develop a loud, knocking quality (not quite as clear as Phase 1).

Phase 4: the sounds suddenly become muffled and again have a faint swishing quality.

Phase 5: the sounds cease.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 12 of 20



Sphygmomanometer

MANOMETER(Pressure Gauge)

COMPRESSIONCUFF

PRESSURECONTROL

VALVE

PRESSUREBULB

6-17

TUBES

Familiarization with the Sphygmomanometer

The compression cuff contains an inflatable rubber bladder.

A tube connects the bladder to the manometer, or pressure gauge. • Another tube connects the bladder to the pressure bulb, which can be squeezed to

inflate the bladder.

• The pressure control valve permits inflation of the bladder and regulates the rate at which the bladder is deflated.

• To inflate the bladder, the pressure control valve must be twisted all the way to the right.

• When the valve is twisted all the way to the right, air can be pumped into the bladder, but no air can escape from the bladder.

• To deflate the bladder, twist the valve to the left.

• The more the valve is twisted to the left, the faster the bladder will deflate. Session 6 – Examinations of Vital Signs


Details of Blood Pressure Measurement

1. Position cuff on bicep so that tubes extend down middle of arm

2. Wrap cuff snugly around bicep

3. Clip manometer to the subject’s sleeve or in a location to easily see the gauge

4. Twist pressure control valve all the way to the right

6-18

Details of Blood Pressure Measurement

• Wrap the cuff snugly around the bicep.

• Clip the manometer (pressure gauge) on the subject’s sleeve, so that it is readily viewable.

• Twist the pressure control valve all the way to the right.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 13 of 20



Details of Blood Pressure Measurement (Cont.)

5. Put stethoscope earpieces in your ears

6. Apply the stethoscope to the brachial artery pulse point

7. Rapidly inflate bladder to a level high enough to squeeze the artery shut (Normally 180)

6-19

• Put the stethoscope earpieces in your ears.

• Place the diaphragm or bell of the stethoscope over the brachial artery.

• Rapidly inflate the bladder to approximately 180mmHg. Session 6 – Examinations of Vital Signs


Details of Blood Pressure Measurement (Cont.)

8. Twist the pressure control valve slightly to the left (pressure should drop at 2 mmHg per second)

9. Keep your eyes on the gauge and listen for the Korotkoff sounds

6-20

• Twist the pressure control valve slightly to the left to release the pressure slowly.

• Keep your eyes on the gauge and listen for the Korotkoff sounds. Session 6 – Examinations of Vital Signs


Blood Pressure Values

• Systolic: 120-140• Diastolic: 70-90

Some people can have significantly different blood pressures

6-21

DRE Average Blood Pressure Values

Systolic: 120-140

Diastolic: 70-90

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 14 of 20



Do’s and Don’ts of Blood Pressure Measurement

6-22

Do’s and Don’ts of Blood Pressure Measurement

If you inflate the bladder and then need to repeat the measurement, wait at least three minutes to allow the subject’s artery to return to normal.

Hold the bell of the stethoscope with your fingers; don’t slide it under the cuff – that will distort the measurement.



Participant’s Initial Practice at Measuring Blood Pressure

6-23

Participant’s Initial Practice at Measuring Blood Pressure

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 15 of 20



Measuring Body Temperature• Oral thermometer recommended• Always use protective disposable

mouthpiece• Position thermometer under

the subject’s tongue• Have subject refrain from talking

when measuring temperature• Refrain from letting subject drink hot or

cold fluids immediately prior to measuring temperature

6-24

C. Demonstrations

Measurement of Temperature

• Temperature is measured orally using a thermometer.

• Ensure that the subject does not take any hot or cold liquids by mouth prior to taking the temperature.



Measuring Pulse Rate

6-25

Pulse Rate Measurement Demonstrations Session 6 – Examinations of Vital Signs


Measuring Blood Pressure

6-26

Blood Pressure Measurement Demonstrations

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 16 of 20



DRE Ranges of Vital Signs

• Pulse Rate:• 60 to 90 beats per minute

• Blood Pressure: • Systolic – 120 to 140 mmHg • Diastolic – 70 to 90 mmHg

• Body Temperature:• 98.6 degrees Fahrenheit plus or minus

one degree

6-27

D. Ranges of Vital Signs

Human vital signs vary between individuals. However, the DEC program has identified a set of ranges for each of the three vital sign examinations used in the drug influence evaluation process. The ranges used in the DEC program are a bit wider than those used by the medical profession.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 17 of 20



Drug Categories and Vital Signs

• All seven categories of drugs ordinarily will affect pulse rate and blood pressure

• Some categories usually will lower pulse and blood pressure

6-28

E. Relationship of Drug Categories to the Vital Signs Examinations

• All seven categories of drugs ordinarily will affect pulse rate and blood pressure.

• Some categories usually will lower pulse and blood pressure.

• CNS Depressants and Narcotic Analgesics usually lower pulse and BP.

• Quaaludes, ETOH and possibly some anti-depressants may cause the pulse to increase.

The other five categories all tend to elevate pulse rate.

• Most of the drug categories that elevate pulse rate also elevate blood pressure.

• CNS Stimulants, Hallucinogens, Dissociative Anesthetics and Cannabis all usually cause blood pressure to rise.

• The vast majority of Inhalants, namely, the volatile solvents and the aerosols, also elevate blood pressure.

• But the remaining small group of Inhalants, the anesthetic gases, actually lowers the blood pressure.

• So for Inhalants, the effect on blood pressure will be up or down.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 18 of 20



Drug Categories and Vital Signs (Cont.)

6-29

Three of the categories usually will cause the body temperature to rise.

The drug PCP and its analogs from the Dissociative Anesthetics category usually increase body temperature; PCP users have been known to remove their clothing to cool down.

CNS Stimulants and Hallucinogens also will usually increase body temperature.

The effect of Inhalants on body temperature depends on the specific substance that is inhaled.

Some inhalants may cause temperature to increase or be down.

But other inhalants may leave the temperature near normal.

One category usually causes body temperature to be lowered.

Narcotic Analgesics usually lower body temperature.

The remaining two categories usually do not affect temperature.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 19 of 20



Drug Categories and Vital Signs (Cont.)

6-30

Which drugs affect muscle tone?

Three of the categories usually will cause the muscle tone to be rigid.

Write “RIGID” on the Muscle Tone line for Stimulants, Dissociative Anesthetics and Hallucinogens.

Two categories usually cause muscle tone to be flaccid.

CNS Depressants and Narcotic Analgesics usually cause a flaccid muscle tone.

One category usually causes normal muscle tone.

Cannabis usually causes normal muscle tone.

One category will usually cause either normal or flaccid muscle tone.

Inhalants usually cause either normal or flaccid muscle tone.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 20 of 20



Drug Categories and Vital Signs

Practice

6-31

F. Practice

• Explanation of Practice

• Teammates will take turns measuring each other’s pulse rate and blood pressure.

• Each participant will write down every measurement he or she makes and the time at which the measurement was made.

• Whichever member of the team is not engaged in taking the measurement or serving as the “suspect” will act as a coach and offer appropriate constructive criticism to his or her teammate.

• Practice will continue until each participant has taken at least three complete pulse and blood pressure measurements on both teammates.



QUESTIONS?

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 1 of 14

Participant Manual DRE Pre School - Session 7 – Overview of Signs and Symptoms

Session 7 – Overview of Signs and Symptoms


• Give examples of specific drugs belonging to the seven drug categories

• Describe the major signs and symptoms of impairment associated with each category

Learning Objectives

7-2


• Give examples of specific drugs belonging to the seven drug categories.

• Describe the major signs and symptoms of impairment associated with each category.


A. CNS Depressants Interactive Discussions B. CNS Stimulants C. Hallucinogens D. Dissociative Anesthetics E. Narcotic Analgesics F. Inhalants G. Cannabis H. Wrap-Up



Session 7

Overview of Signs and Symptoms

75 Minutes



Session 7

Overview of Signs and Symptoms

75 Minutes Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 2 of 14



• Sign: An observable or detectable indicator of drug influence

• Symptom: A subjective indicator of drug influence that is reported by the drug impaired subject

Sign and Symptom Definition

7-3

• Sign: An observable or detectable indicator of drug influence (i.e., dilated pupils, high blood pressure).

• Symptom: A subjective indicator of drug influence that is reported by the drug impaired subject (i.e., “I feel nauseous.”)



• HGN ?

• VGN ?

• LOC ?

CNS Depressants

7-4

A. CNS Depressants

Central Nervous System Depressants is a category that includes many different drugs.

Indicators of CNS Depressant Influence Found in Eye Exams HGN usually will be present. Vertical Gaze Nystagmus may be present, especially with high doses (for that individual) of Depressants

Under the influence of Depressants, Lack of Convergence usually will be present.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 3 of 14



• Pupil size ?

CNS Depressants

7-5

Depressants usually do not affect pupil size; therefore, the pupils will normally be in the average range.

But some specific Depressant drugs do affect pupil size. Soma, Methaqualone (Quaaludes) and some anti-depressants usually dilate pupils.

Depressants generally will cause pupillary reaction to light to be sluggish. Session 7 – Overview of Signs and Symptoms


Vital signs ?

• Pulse rate

• Blood pressure

• Body temperature

CNS Depressants

7-6

Indicators of CNS Depressant Influence Found in Checks of the Vital Signs Depressants usually lower pulse rate.

But some specific Depressant drugs may elevate the pulse. Methaqualone (Quaaludes), alcohol and possibly some anti-depressants may cause elevation in pulse rate.

Depressants usually lower blood pressure.

Depressants usually leave temperature near normal. Depressants usually cause flaccid muscle tone.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 4 of 14



• HGN ?

• VGN ?

• LOC ?

CNS Stimulants

7-7

B. CNS Stimulants

The category called Central Nervous System Stimulants includes many drugs. Indicators of CNS Stimulant Influence Found in Eye Exams

HGN will not be present.

Vertical Gaze Nystagmus will not be present.



• Pupil size ?

CNS Stimulants

7-8

CNS Stimulants usually cause the pupils to dilate.

We have seen that CNS Depressants effect pupillary reaction; similarly, CNS Stimulants may cause a slowing in the pupillary reaction to light.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 5 of 14



Vital signs ?

• Pulse rate

• Blood pressure


CNS Stimulants

7-9

Indicators of CNS Stimulant Influence Found in Checks of Vital Signs

CNS Stimulants usually increase pulse rate.

CNS Stimulants usually increase blood pressure.

CNS Stimulants usually elevate body temperature.

CNS Stimulants usually cause a rigid muscle tone.

Though not directly related to the vital signs, the evaluator may find the subject’s muscle tone to be rigid with possible body tremors. A grinding of the teeth, referred to as “bruxism” may also be noticed.



• HGN ?

• VGN ?

• LOC ?

Hallucinogens

7-10

C. Hallucinogens

Hallucinogens include some naturally occurring substances as well as some synthetic drugs.

Indicators of Hallucinogen Influence Found in Eye Exams



Under the influence of Hallucinogens, the eyes should still be able to converge; therefore, lack of convergence will not be present.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 6 of 14



• Pupil size ?

Hallucinogens

7-11

Hallucinogens usually cause the pupils to dilate.

Normally, Hallucinogens do not effect pupillary reaction to light.

However, certain psychedelic amphetamines may cause a slowing in the pupillary reaction.



Vital signs ?

• Pulse rate

• Blood pressure


Hallucinogens

7-12

Indicators of Hallucinogen Influence Found in Checks of Vital Signs

Hallucinogens usually increase pulse rate.

Hallucinogens usually increase blood pressure. Hallucinogens usually elevate body temperature.

Hallucinogens usually cause a rigid muscle tone.

If we only had these major signs to go by, it would be difficult to distinguish between someone under the influence of CNS Stimulants from someone under the influence of Hallucinogens.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 7 of 14



• HGN ?

• VGN ?

• LOC ?


7-13

D. Dissociative Anesthetics

The category called Dissociative Anesthetics consists of the drug PCP, its various analogs and Dextromethorphan. • An ‘analog’ of PCP is a drug that is a ‘chemical first cousin’ of PCP; that is, it is a

drug that has a slightly different molecular structure from that of PCP, but produces the same effects as PCP.

• One of the most popular analogs of PCP is the drug called Ketamine.

• Ketamine is a legally manufactured (but controlled) drug that is used as an anesthetic in some surgical applications.

• Some other analogs of PCP include Ketalar, Ketaset, and Ketajet.

• Dextromethorphan is a drug found in numerous over-the-counter substances.



• HGN ?

• VGN ?

• LOC ?

Dissociative Anesthetics (Cont.)

7-14

Indicators of the Dissociative Anesthetics Found in Eye Exams

HGN usually will be present, and often with a very early onset.

Vertical Gaze Nystagmus usually will be present.

Lack of Convergence usually will be present.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 8 of 14



• Pupil size ?


7-15

Dissociative Anesthetics do not normally effect pupil size; therefore, a person under the influence of a Dissociative Anesthetic, such as PCP usually will have pupils that are in the DRE average ranges.

Dissociative Anesthetics normally will not effect pupillary reaction to light.



Vital signs ?

• Pulse rate

• Blood pressure



7-16

Indicators of Dissociative Anesthetic Influence Found in Checks of Vital Signs

Dissociative Anesthetics usually increase pulse rate.

Dissociative Anesthetics usually elevate blood pressure.

PCP and its analogs usually elevate body temperature. Dextromethorphan may or may not rise temperature.

Dissociative Anesthetics usually cause rigid muscle tone.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 9 of 14



• HGN ?

• VGN ?

• LOC ?

Narcotic Analgesics

7-17

E. Narcotic Analgesics

Narcotic Analgesics include some natural derivatives of opium as well as some synthetic drugs.

Indicators of Narcotic Analgesic Influence Found in Eye Exams



Under the influence of Narcotics, the eyes should still be able to converge; therefore, Lack of Convergence usually is not present.



• Pupil size?

Narcotic Analgesics

7-18

Narcotic Analgesics usually cause a very noticeable constriction of the pupils.

Though there is always some reaction to light, the constricted pupils caused by Narcotic Analgesics can make it nearly impossible to perceive a change in pupil size. However, when observed it will generally be little or none visible.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13

HS 172A R5/13 10 of 14



Vital signs?

• Pulse rate

• Blood pressure


Narcotic Analgesics

7-19

Indicators of Narcotic Analgesic Influence Found in Checks of Vital Signs Narcotic Analgesics usually lower pulse rate.

Narcotic Analgesics usually lower blood pressure.

Narcotic Analgesics usually lower body temperature.

With a Narcotic Analgesic, muscle tone will be flaccid.



• HGN ?

• VGN ?

• LOC ?

Inhalants

7-20

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13

HS 172A R5/13 11 of 14



• HGN ?

• VGN ?

• LOC ?

Inhalants

7-20

F. Inhalants

The category of Inhalants includes a wide variety of gases and fumes that have mind-altering effects. • Not all Inhalants affect their users in exactly the same way.

• There is probably less consistency in the signs and symptoms of Inhalants than there is with any other category.

• When we talk of the signs and symptoms of Inhalants, we often must qualify our statements.

• For example, we may say that a particular effect will be observed “for most Inhalants.”

Indicators of Inhalant Influence Found in Eye Exams With most Inhalants, HGN usually will be present.

With most Inhalants, Vertical Gaze Nystagmus may be present, especially with large doses.

Under the influence of Inhalants, Lack of Convergence usually will be present.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 12 of 14



• Pupil size ?

Inhalants

7-21

The effect of Inhalants on pupil size depends on the particular substance inhaled. Most inhalants usually leave the pupils in the DRE average ranges.

Some inhalants may cause pupil dilation.

Depending on the substance used, Inhalants may cause a slowed reaction to light or the pupils may react normally. However, the most frequently observed effect will be a sluggish reaction to light.



Vital signs ?

• Pulse rate

• Blood pressure


Inhalants

7-22

Indicators of Inhalant Influence Found in Checks of Vital Signs

Inhalants usually elevate pulse rate.

Most inhalants usually elevate blood pressure, but some lower blood pressure.

The effects of Inhalants on temperature depend on the particular substance inhaled.

Depending on the Inhalant, muscle tone will either be normal or flaccid.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 13 of 14



• HGN ?

• VGN ?

• LOC ?

Cannabis

7-23

G. Cannabis

Indicators of Cannabis Influence Found in Eye Exams



Under the influence of Cannabis, Lack of Convergence will be present. Session 7 – Overview of Signs and Symptoms


• Pupil size?

Cannabis

7-24

Under the influence of Cannabis, the pupils may be dilated or possibly within the DRE average ranges.

The pupillary reaction to light will appear normal when under the influence of Cannabis.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 14 of 14



Vital signs ?

• Pulse rate

• Blood pressure


Cannabis

7-25

Indicators of Cannabis Influence Found in Checks of Vital Signs Cannabis usually elevates pulse rate.

Cannabis usually elevates blood pressure.

Cannabis usually leaves temperature near the average body temperature ranges.

Cannabis usually causes normal muscle tone.



Matrix summarizes the major signs of drug influence that are observed by DREs

Wrap Up

7-26

H. Wrap-Up



QUESTIONS?

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 1 of 23

Participant Manual DRE Pre School - Session 8 – Alcohol as a Drug Session 8 – Alcohol as a Drug


Session 8

Alcohol as a Drug

90 Minutes

Session 8 – Alcohol as a Drug


• Describe a brief history of alcohol• Identify common types of alcohol• Describe the physiological processes of

absorption, distribution and elimination of alcohol in the human body

• Describe dose response relationships that impact on alcohol’s impairing effects

Learning Objectives

8-2


• Describe a brief history of alcohol.

• Identify common types of alcohols.

• Describe the physiological processes of absorption, distribution and elimination of alcohol in the human body.

• Describe does response relationships that impact alcohol’s impairing effects.


A. Brief Overview of Alcohol Instructor-Led Presentations B. Physiological Processes Oral Quiz C. Symptomatology of Alcohol D. Dose-Response Relationships E. Questions for Review

• Alcohol is a drug. In fact, alcohol is the most commonly abused drug. • As DREs, the participants will often encounter persons who are under the

combined influence of alcohol and some other drug.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 2 of 23



A family of closely-related chemicals whose molecules are made up of hydrogen, carbon and oxygen

Alcohol

8-3

H H

H C C OH

H H

A. Brief Overview of Alcohol

The word “alcohol” refers to a number of distinct but similar chemicals.

• Each of the chemicals that is called an “alcohol” is composed of the three elements: hydrogen, carbon, and oxygen.

• Each of the “alcohols” is a drug within the scope of our definition.

• But only one can be tolerated by the human body in substantial quantities. Session 8 – Alcohol as a Drug


Some Types of Alcohol

METHYL ALCOHOL(Methanol)

ETHYL ALCOHOL(Ethanol)

ISOPROPYL ALCOHOL(Isopropanol)

8-4

Common Alcohols

Three of the more commonly known “alcohols” are Methyl, Ethyl, and Isopropyl.

• Methyl Alcohol, also known as Methanol, or “wood alcohol.”

• Ethyl Alcohol, also known as Ethanol, or “beverage alcohol.”

• Isopropyl Alcohol, also known as Isopropanol, or “rubbing alcohol.”

Ethanol Alcohol

Ethanol is the kind of alcohol on which we will focus, because it is the only type intended for human consumption.

• Ethanol is the active ingredient in beer, wine, whiskey, and other alcoholic beverages intended for drinking.

• Like all “alcohols,” ethanol is composed of hydrogen, carbon and oxygen.

• Chemists use a number of different symbols to represent ethanol.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 3 of 23



Ethyl Alcohol(Intended for human consumption)

Chemical Symbols:

• ETOH

• C2H5OH

Ethanol

8-5

• For our purposes, we will use the symbol “ETOH.”

• The “ET” represents “ethyl” and the “OH” represents an oxygen atom and hydrogen atom, bonded together in what the chemists refer to as the “hydroxyl radical.” All alcohols have a hydroxyl radical in their molecules.

Ethanol has been around for a long time. People drank it long before they learned to write.



• FERMENTATION

Yeast combines with sugars from fruit or grains in a chemical reaction that results in ETOH

Production of Ethanol

8-6

Ethanol is a naturally occurring drug. That is, it is produced through a process called fermentation.

In fermentation, spores of yeast, carried by the wind, come in contact with fruit or grain that has fallen to the ground.

Sugars in the fruit or grain chemically react with yeast, and produce ethanol.

Humans almost certainly first encountered ethanol that had been produced accidentally in this fashion.

Of course, today we don’t sit around waiting for the wind to bring yeast to fallen fruit. Most fermentation takes place on purpose, under controlled conditions. Through the process of fermentation, we can produce a beverage that has, at most, about 14% ethanol. When the ethanol concentration reaches 14%, the yeast die,so fermentation stops.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 4 of 23



• FERMENTATIONYeast combines with sugars from fruit or grains in a chemical reaction that results in ETOH

• DISTILLATIONFermented beverage is boiled at a controlled temperature to extract and concentrate the ethanol fumes

Production of Ethanol

8-7

If we want to have higher concentration ethanol beverages, we have to use another step in the production.

Distillation is the process used to produce a higher concentration of ethanol. In distillation, a fermented beverage is heated to the point where the ethanol begins to boil.

• Ethanol starts to boil at a lower temperature than water.

• The ethanol vapor is collected and allowed to cool until it turns back into a liquid.

• By repeating the process of heating the liquid and collecting and cooling the vapors, higher and higher concentrations of ethanol can be produced.

• Ethanol beverages that are produced by distillation are called distilled spirits. Over the centuries in which people have produced ethanol, some general or common sized servings of different beverages have evolved.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 5 of 23



Bottle of Beer• 12 ounces of fluid @ 4% alcohol

equals 0.48 ounces of pure alcohol

Glass of Wine• 4 ounces of fluid @ 12% alcohol


Shot of Whiskey (80-Proof)• 1 and 1/4 ounces @ 40% alcohol


Common Drink Sizes

8-8

• Beer is usually served in 12-ounce cans or bottles. Since beer averages an ethanol concentration of four percent, a can or bottle contains a bit less than one-half ounce of pure ethanol.

• Four ounces of wine with an alcohol concentration of 12% contains approximately one half ounce of pure alcohol.

• Whiskey and other distilled spirits are dispensed in a “shot” glass, which usually contain one and one-quarter ounces of liquid.

• Since whiskey usually has an ethanol concentration of 40%, a “shot” of whiskey has exactly one-half ounce of pure ethanol.

For all practical purposes, standard sized servings of beer, wine, and whiskey all pack the same “punch.”

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 6 of 23



Alcohol is a CNS Depressant

Alcohol Is The Most Abused Drug In The

United States

8-9

B. Physiological Processes

Alcohol is the most abused drug in the United States.

Ethanol is a Central Nervous System Depressant.

• It doesn’t impair until it gets into the brain.

• It can’t get into the brain until it first gets into the blood.

• It can’t get into the blood until it first gets into the body.

There are a number of ways in which alcohol can get into the body.

• It can be injected into a vein via hypodermic needle.

• It can be inhaled, i.e., alcohol fumes can be brought into the lungs, and some molecules will pass into the blood.

• It could also be inserted as an enema and ingested by quickly passing from the large intestine into the blood.

But the vast majority of times that alcohol gets into the body, it gets there via drinking.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 7 of 23



Getting the ethanol out of the stomach and into the blood

Absorption of Alcohol

8-10

20%

20%

20%

20%

StomachWalls

20%Stomach

Walls

StomachWalls

Once the alcohol is in the stomach, it will take two routes to get into the blood.

• One interesting thing about alcohol is that it is able to pass directly through the stomach walls.

• Under normal conditions, about 20% of the alcohol a person drinks gets into the blood by diffusing through the walls of the stomach.

• But most of the alcohol usually passes through the base of the stomach into the small intestine, from which it passes quickly into the blood.

• Another interesting thing about alcohol is that it does not have to be digested before it can move from the stomach to the small intestine.

• When a person eats food, the food must remain for a time in the stomach.

• Acids and enzymes in the stomach must begin to break down the food to prepare it to pass to the lower portion of the gastrointestinal track.

• While the initial digestive process is underway, a muscle at the base of the stomach will constrict, and shut off the passage to the small intestine.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Absorption of Alcohol (Cont.)

8-11

20%

20%

20%

20%Pylorus

StomachWalls

StomachWalls

StomachWalls

80%

Getting the ethanol out of the stomach and into the blood

20%

• Note the muscle called the pylorus, or pyloric valve.

• Since alcohol doesn’t have to be digested, the pylorus does not constrict when alcohol enters the stomach.

• If we drink on an empty stomach, the pylorus stays wide open.

• The alcohol will pass immediately through the base of the stomach, into the small intestine, and quickly move into the bloodstream.

• Food will cause the pylorus to constrict.

• While the pylorus is closed, nothing will move from the stomach to the small intestine.

• Any alcohol that is in the stomach will be “trapped” there, along with the food.

• The alcohol will not get into the blood as quickly, and the blood alcohol concentration will not get as high, as if the drinking had been done on an empty stomach.

• While the alcohol is trapped in the stomach, the acids and enzymes will start to react with it and break it down.

• By the time the pylorus opens, some of the alcohol will have been chemically changed, so there will be less available to get into the blood.

• Once the alcohol gets into the blood, the blood will carry it to the various tissues and organs of the body

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Getting the ethanol into the body’s tissues and organs

Basic Principle:

• Ethanol goes wherever it finds water

Distribution of Alcohol

8-12

• Alcohol is attracted to water. The blood will deposit the alcohol in all the parts of the body where water is found.

• Parts of the body that have a lot of water will receive a lot of alcohol.

• Parts of the body that have only a little water will receive little alcohol. Session 8 – Alcohol as a Drug


Which Parts of the Body Have a Lot of Water?

8-13

Which Parts Contain Very Little Water?

BRAIN LIVER MUSCLE TISSUE KIDNEY

BONES FATTY TISSUE

• Brain

• Liver

• Muscle tissue

• Kidney

• Bones

• Fatty tissue

The fatty tissue will receive very little of the alcohol. The muscle tissue will receive a relatively high proportion of the alcohol that a person drinks.

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• The average male is 68 percent water

• The average female is only 55 percent water

Significant Difference Between Men and Women

8-14

Here is an interesting and significant difference between men and women: pound-for-pound, the average male has much more water in his body than the average female. • The female body has more fatty tissue than does the male body.

• Pound-for-pound, the average female has more fat and less muscle than does the average male.

• Since fatty tissue has very little water, the average female, pound-for-pound, has less water than the average male.

• This means that the average woman has fewer places in her body in which to deposit the alcohol she drinks.

• The woman’s blood alcohol concentration will be higher than the man’s because she has less water in which to distribute the alcohol.

• As soon as alcohol gets into the body, the body begins working to get rid of it.

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Getting the ethanol out of the body:

Direct Excretion:

• Breath, sweat, tears, urine, etc.

Metabolism:

• Primarily in the liver

Elimination of Alcohol

8-15

• Some alcohol is simply expelled directly from the body, i.e., on the breath, in the sweat, in urine, etc.

• Relatively little of the alcohol we drink is directly expelled from the body.

Clarification: Only about 2 – 10% of the alcohol we consume is directly excreted in the breath, urine, etc.

• The body eliminates most of the alcohol by chemically breaking it down.

• The liver is primarily responsible for breaking down, or metabolizing, the alcohol.

Clarification: Some metabolism of alcohol also takes place in other parts of the body, including the brain. The liver does the vast majority of the job.



• The liver burns the ethanol (i.e., causes a chemical reaction of ethanol with oxygen)

• The process is aided by an enzyme called alcohol dehydrogenase

• The ultimate products of the chemical reaction are carbon dioxide and water

Metabolism in the Liver

8-16

• Metabolism of alcohol actually consists of a slow, controlled burning of the alcohol.

• In the burning process, the alcohol combines with oxygen.

• The liver has an enzyme called alcohol dehydrogenase, which helps to speed up the reaction of oxygen with the alcohol.

Clarification: The enzyme does not react with the alcohol itself, but simply makes it easier for the oxygen to react with the alcohol. The technical term for something that helps a chemical reaction while not itself taking part in the reaction is a catalyst. Alcohol dehydrogenase is a catalyst for the metabolism of alcohol.

• The reaction of alcohol with oxygen ultimately produces carbon dioxide and water, which can be directly expelled from the body.

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• Due to metabolism, the average person’s BAC drops by about 0.015 per hour

Metabolism in the Liver

8-17

The speed with which the liver burns alcohol varies from person to person, and will change from time to time for any particular person.

• BUT ON THE AVERAGE: Due to metabolism, a person’s BAC will drop by about 0.015 per hour. For the average male, a BAC of 0.015 is equal to the alcohol content of about two-thirds of a “standard drink”. i.e., about two-thirds of a can of beer, or about two-thirds of a glass of wine, or two-thirds of a shot of whiskey.

• For the average woman, a BAC of 0.015 is equal to the alcohol content of only one-half of a “standard drink.” So the average male can “burn up” about two-thirds of a drink in an hour. But the average female can only burn up about one-half of a drink in an hour.

• In other words: suppose a person gulps down a can of beer, or a glass of wine, or a shot of whiskey; if the person is an average man, it will take him about an hour and one-half to burn up that alcohol; if the person is a woman, it will take her about two hours.

• We can’t speed it up.

• Drinking coffee won’t help.

• A cold shower won’t help.

• Exercise won’t help.

• Our livers take their own sweet time burning the alcohol.

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Alcohol Symptomatology

8-18

ALCOHOLHGN Present

VGN Present (HIGH DOSES)

LACK CONV Present

C. Symptomatology of Alcohol

• ETOH may elevate the pulse rate in lower BAC levels.

Indicators of Alcohol Influence Found in Eye Exams

• HGN will be present.

• Vertical Gaze Nystagmus may be present, especially with high doses (for that individual) of alcohol.

• Under the influence of alcohol, Lack of Convergence frequently will be present. Session 8 – Alcohol as a Drug


Alcohol Symptomatology (Cont.)

8-19

ALCOHOLHGNVGN

LACK CONVPUPIL SIZERCTN LIGHTPULSE RATE

BLOOD PRESSTEMP

MUSCLE TONE

• Alcohol does not affect pupil size; therefore, alcohol usually leaves the pupils in the DRE Average ranges.

• Alcohol will cause pupillary reaction to light to be sluggish.

• Indicators of Alcohol Influence Found in Checks of Vital Signs • Pulse rate will usually be down. However, some subjects have been found to have

elevated pulse rates at lower BACs.

• Blood pressure response to alcohol will normally be down.

• Alcohol usually leaves body temperature near the average range.

• Alcohol usually causes flaccid muscle tone.

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Alcohol Symptomatology (Cont.)

8-20

ALCOHOLHGN PresentVGN Present (High Doses)

LACK CONV PresentPUPIL SIZE Normal RCTN LIGHT SlowPULSE RATE Down

BLOOD PRESS DownTEMP Normal

MUSCLE TONE Flaccid



What does it mean?BAC is the number of grams of alcohol found in 100 milliliters of the person’s

blood.Example:

If a person has a BAC of .08, it means there is 0.08 grams of ethanol in every 100 milliliters (ml) of his or her blood.

Blood Alcohol Concentration

8-21

D. Dose-Response Relationships What does “Blood Alcohol Concentration” mean? BAC is the number of grams of alcohol found in 100 milliliters of the person’s blood.

Example:

If a person has a BAC of .08, it means there is 0.08 grams of ethanol in every 100 milliliters (ml) of his or her blood.

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A “gram” is pretty light (it takes almost 500 grams to make one pound)One gram is equal to one thousand milligrams.One-tenth of a gram therefore is equal to one hundred milligrams.So if a person has a BAC of 0.10, he or she has 100 milligrams of alcohol in every 100 milliliters of blood. That is the same as one milligram in every milliliter.

Grams, Milligrams and Nanograms

8-22

• Blood alcohol concentration means the number of grams of pure ethanol that are found in every 100 milliliters of a person’s blood.

• A gram is a measure of weight; it takes almost 500 grams to make a pound.

• The so-called “illegal limit” of BAC is 0.08 in all states.

• In 2005, all 50 states had adopted 0.08 BAC.

• If a person has a BAC of 0.08, it means there is 0.08 grams (g) of ethanol in every 100 milliliters (ml) of his/her blood.

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How Much Alcohol Does a Person Have to Drink

to Reach a BAC of 0.08?

8-23

• Take an average male weighing 175 pounds and in reasonably good physical shape.

• Assume he does his drinking on an empty stomach.

• He would have to gulp down about 4 to 5 cans of beer, or 4 to 5 glasses of wine, or five shots of whiskey in a fairly short period of time to reach 0.08 BAC.

• In terms of pure ethanol, that would amount to just about two and one-half fluid ounces, or about two shot glasses.

• If these two shot glasses were filled with pure ethanol, we would have just enough of • In one respect, it certainly doesn’t take much ethanol to impair; just two full shot

glasses will more than do the trick for a full-sized man.

• BUT COMPARED TO OTHER DRUGS, it takes an enormous quantity of ethanol to cause impairment.

• In order to compare ethanol to other drugs, we have to review some more units of weight.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 17 of 23



• One milligram is equal to one million nanograms. (A nanogram is very light: it takes almost 500 billion of them to make a pound.)

• A person whose BAC is 0.10 has one million nanograms of alcohol in every milliliter of blood.

How does alcohol compare with other drugs?

More on Grams and Nanograms

8-24

• We’re already familiar with the gram. It weighs only about one five-hundredth of a pound.

• The milligram is much lighter still and it takes about one thousand milligrams to make a gram.

• If one gram is equal to one thousand milligrams, then one tenth of a gram is equal to one hundred milligrams.

• Now reveal the remainder of visual.

• Clarification: 100 is one-tenth of 1,000.

• So a person with a BAC of 0.10 has 100 milligrams of ethanol in every 100 milliliters of his or her blood.

• That is exactly the same as saying there is one milligram of ethanol in every one milliliter of blood.



• One milligram is equal to one million nanograms. (A nanogram is very light: it takes almost 500 billion of them to make a pound.)

• A person whose BAC is 0.10 has one million nanograms of alcohol in every milliliter of blood.

How does alcohol compare with other drugs?

More on Grams and Nanograms

8-25

Here is a new term: the nanogram.

It takes a million nanograms to make a milligram.

That means it takes one billion nanograms to make a gram.

And that means that it takes almost five hundred billion nanograms to make a single pound.

So if a person’s BAC is 0.10, he or she has one million nanograms of pure ethanol in every milliliter of blood.

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Drug Concentrations Typically Associated With “Significant”

Impairment

8-26

Drug NANOGRAMS per MILLILITER

ALCOHOL 500,000 to 1,000,000

• IT IS MOST IMPORTANT to understand that we cannot state exact correspondences between alcohol concentrations and other drug concentrations.

• For example, we can say that someone with a blood alcohol concentration between 0.05 and 0.10 will exhibit significant impairment because there is a large body of scientific research that backs up that statement.

• So we can say that research shows that significant impairment will be found with alcohol at concentrations of 500,000 to one million nanograms per milliliter.

• But we can’t say exactly how much cocaine, THC, morphine, or any other drug would take to produce exactly the same impairment that we would find at 0.10 BAC.

• In part, this is because we do not have extensive scientific research for most other drugs.

• But also it is because many other drugs do not impair in the same way that alcohol impairs.

• Nevertheless, based on the available research, it is possible to make some general statements about drug concentrations that can safely be said to induce significant driving impairment.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Impairment (Cont.)

8-27


ALCOHOL 500,000 to 1,000,000

AMPHETAMINES 100 to 300

THC 50 to 100

• First example: Amphetamines. • Researchers agree that if we had two shot glasses full of pure amphetamines we’d

have enough to impair as many as ten thousand people.

• Second example: Cannabis.

• Available evidence suggests that if these two little glasses were full of pure THC, we’d have enough drug to impair as many as twenty thousand people.

• Ask participants: But what if these glasses were full of pure LSD?

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Impairment (Cont.)

8-28


ALCOHOL 500,000 to 1,000,000

AMPHETAMINES 100 to 300

THC 50 to 100

LSD 1 to 2

• Many researchers believe that significant impairment results from very low LSD concentrations.

• If these two glasses contained pure LSD, we could impair up to one million people.

• What does all this mean? This is a rhetorical question.

• First, it means that compared to alcohol, most other drugs are very powerful: a little goes a long way.

Example: A person who is “only” carrying one fluid ounce of LSD (hold up one shot glass) would be capable of impairing “only” the entire population of, say, Wyoming.

• Second, it means that laboratories may be stretched to the limits of their technologic capabilities when we send them samples and request certain drug analyses.

• All analytic techniques have detection thresholds, i.e., minimum concentrations of drugs that must be present if a scientific confirmation of the presence of the drug is to be obtained.

• If the concentration of the drug is less than the detection threshold, the laboratory simply will not be able to confirm that the drug is present.

• The problem is that some people will be significantly impaired at drug concentrations that are below the lab’s detection threshold.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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“No Drugs Were Found”

8-29

• What this means is that a DRE sometimes examines a subject, concludes correctly that he or she is under the influence of a certain drug category, perhaps even obtains an admission from the subject that he or she has taken a drug, gets a toxicological sample and sends it to the lab, only to have the lab report that “no drugs were found.”

• When this happens to you – and it will – it is important that you don’t let yourself become discouraged.

• As a DRE, all you are expected to do is the best that you can do given the tools available.

• You will never become perfect in your opinion of drug impairment.

• There will be times when you will “miss” the fact that a subject is impaired.

• And there may be times when you will conclude that a subject is under the influence of a drug and a drug will not be detected.

• We rely on the laboratory to corroborate our opinions.

• However, the laboratory is not perfect and the toxicologists won’t always be able to corroborate your opinion, even though your opinion is accurate.



QUESTIONS?

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HS 172A R5/13

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E. Questions for Review

1. Name three different chemicals that are alcohols. Which of these is beverage alcohol, intended for human consumption? What is the chemical symbol for beverage alcohol?

2. What is the name of the chemical process by which beverage alcohol is produced naturally? What is the name of the process used to produce high-concentration beverage alcohol?

3. Multiple Choice: “Blood alcohol concentration is the number of __________ of alcohol in every 100 millimeters of blood.”

4. True or False: Pound-for-pound, the average woman contains more water than does

the average man.

5. What do we mean by the “proof” of an alcoholic beverage?

6. Every chemical that is an “alcohol” contains what three elements?

7. True or False: Most of the alcohol that a person drinks is absorbed into the blood via the small intestine.

8. What is the name of the muscle that controls the passage from the stomach to the lower gastrointestinal tract?

9. True or False: Alcohol can pass directly through the stomach walls and enter the bloodstream.

HS 172A R5/13 23 of 23

10. Multiple Choice: Suppose a man and a woman who both weigh 160 pounds arrived at a party and started to drink at the same time. And suppose that, two hours later, they both have a BAC of 0.10. Chances are….

11. In which organ of the body does most of the metabolism of the alcohol take place?

12. What is the name of the enzyme that aids the metabolism of alcohol?

13. Once a person reaches his or her peak BAC, it will drop at a rate of about __________ per hour.

14. Multiple Choice: If a person has a blood alcohol concentration of 0.10, then there are __________ nanograms of alcohol in every milliliter of his or her blood.

15. True or False: It takes about thirty minutes for the average 175 pound man to “burn off” the alcohol in one 12-ounce can of beer.

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Participant Manual DRE Pre School - Session 9 – Preparing for the DRE School Session 9 – Preparing for the DRE School


Session 9

Preparing for the DRE School

30 Minutes

Session 9 – Preparing for the DRE School


The participant will be informed of the logistics and other arrangements necessary for their participation in the seven-day DRE school

Learning Objective

9-2

Upon successfully completing this session the student will be informed of the logistics and other arrangements necessary for their participation in the seven day DRE School.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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HS 172A R5/13 2 of 2



• Dates

• Location

• Dress Code

• Material Needed

• Transportation

• Lodging

• Other

Seven-Day DRE School

9-3

A. Session 9 Guide

• Dates of the seven-day school

• Location of the school

• Dress code

• Materials that the participants should bring to the school

• Transportation arrangement (if applicable)

• Lodging arrangements (if applicable)

• Recreational facilities and opportunities (if appropriate)



QUESTIONS?

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Participant Manual DRE Pre School - Session 10 – Conclusion of the Preliminary Training

Session 10 – Conclusion of the Preliminary Training


Session 10

Conclusion of the Preliminary Training

45 Minutes



• Demonstrate knowledge of the concepts covered during the training

• Offer anonymous comments and criticisms concerning the school

Learning Objective

10-2


• Demonstrated his or her knowledge of the concepts covered during the DRE Pre-

School.

• Offer anonymous comments and criticisms concerning the school


A. Post-Test and Critique Written Examinations B. Certificates and Dismissal C. Session Wrap-up

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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HS 172A R5/13 2 of 3



Post-Test and Critique

A. Post Test and Critique

Post Test

• Hand out copies of the post-test. • Allow about 15 minutes for students to complete the test.

Critique

• Hand out copies of the Student’s Critique Form.

• Allow about 15 minutes for students to complete the critique.

Review of the Post Test

• Go over the post test questions. Limit this review to 10 minutes. Instruct

the students to retain the Pre-School post-test as a study guide for the

upcoming DRE School.

Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HS 172A R5/13 3 of 3



Certificates and Dismissal

You have successfully completed theDRE Pre-School Training

conducted here

B. Certificates and Dismissal

Hand out certificates of course completion.

Hand back the students’ Certification Progress Logs.

• Making sure that an instructor has signed the Pre-School line on each log.

• Remind the students that they must bring the progress logs with them to the DRE School.



QUESTIONS?

C. Session Wrap-Up

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